Columbia  ^nibersitp   ^"^"^^ 
in  tfje  Cit  p  of  i^in  ^ovk 

CoUege  of  ^Ijpjiiciang  anb  burgeons! 


i^eference  I^ibrarp 


HEADACHES: 


THEIR 


CAUSES,  NATURE,  AND  TREATMENT 


HEADACHES: 
THEIR  CAUSES,  NATURE,  AND  TREATMENT. 


OCTAVO  SERIES  OF  STANDARD  MEDICAL  BOOKS. 
Price,  Strong  Paper  Covers,  75  Cents  ;  Cloth,  $1.25. 


By  William  Henry  Day,  M.  D., 

Author  of  "A  Systematic  Treatise  on  tlie  Diseases  of  Children,"  Physician  to  the  Samaritan  Hospital  for 

Women  and  Children. 


FOURTH  EDITION,— ILLUSTRATED, 


OPINIONS  OF  THE  PRESS. 


"  Dr.  Day  gives  an  exceUent  account  of  the  nature  and  origin  of  bilious 
headache,  and  the  directions  for  treatment  are  full  and  clear.  The  chapter 
on  headaches  in  childhood  and  early  life  is  worthy  of  careful  perusal.  Dr. 
Day  gives  some  excellent  advice  on  the  management  of  children  during  their 
school  life ;  and  this  portion  of  his  book  might  be  read  with  advantage  by 
all  intelligent  persons. ' ' — Medical  Examiner. 

"  The  chief  value  of  the  work  consists  in  the  wealth  of  resources  at  the 
command  of  the  author,  arid  the  practical  value  of  his  therapeutical  sugges- 
tions. ' ' — New  York  Medical  Record. 

''Well  worth  reading.  The  remarks  on  treatment  are  very  sensible." — 
Boston  Medical  afid  Surgical  Journal. 

"  No  practitioner  could  fail  to  read  it  without  obtaining  many  a  hint  of 
value  to  him  in  his  daily  work. ' ' —  Westjninsfer  Review. 

"  The  best  we  have  yet  read  on  the  subject.  One  of  those  works  that  will 
be  found  very  useful  to  the  young  practitioner. ' ' — Medical  Press  and  Circidar. 

''Dr.  Day's  strongest  sections  are,  perhaps,  the  large  and  important 
division  of  nervous  headaches,  and  the  whole  class  of  headaches  incidental 
to  children,  noting  his  cases  with  quick  and  keen  intelligence  of  symptoms, 
and  with  admirable  perspicacity." — The  London  Quarterly  Review. 

"As  a  really  useful  manual  for  the  practitioner  it  will  take  a  high  rank, 
and  will  be  found  well  worth  diligent  perusal." — Philadelphia  Medical  and 
Surgical  Reporter. 


'The  following  books  are  also  in  the  Octavo  Series.  Price,  in  paper 
cover,  75  cents;  cloth,  $1.25.  Beale  on  Slight  Ailments ;  Agnew,  Female 
Perineum  ;  Allingham  on  the  Rectum ;  Tilt,  Change  of  Life ;  Hewitt,  Dis- 
eases of  Women,  2  parts  in  one.     Send  for  circular  with  special  rates. 

R  BLAKISTON,  SON  &  CO.,  Publishers, 

1012  Walnut  Street,  PMladelphia,  Pa. 


HEADACHES : 


NATURE,  CAUSES,  AND  TREATMENT. 


WILLIAM   HENRY  DAY,  M.  D., 

MEMBER  OF  THE   ROYAL  COLLEGE  OF   PHYSICIANS  OF  LONDON,  PHYSICIAN  TO  THE  SAMARI- 
TAN HOSPITAL  FOR   WOMEN  AND  CHILDREN,  AND  AUTHOR  OF  A  "  SYSTEMATIC 

TREATISE  ON    THE   DISEASES  OF  CHILDREN." 


^^  The  first  requisite  for  success  in  life  is  to  be  a  good  animal.'''' 

Herbert  Spencer. 


FOURTH  EDITION. 

WITH  ILLUSTRATIONS 


PHIDADELPHIA: 
P.  BLAKISTON,  SON  &  CO.,  1012  WALNUT  STREET, 

1883. 


BRAIN  OF  MAN. 
I,  2,  3,  frontal  convolutions;  4,  5,  6,  A  and  B,  parietal  convolutions;  7,  8,  9,  temporo- 
sphenoidal  convolutions ;  10,  1 1, 12, occipital  convolutions.     A  is  the  supramarginal  lobule; 
B  is  the  postero-parietal  lobule;  and  /3  on  the  bridging  or  annectent  convolutions;  R,  fis- 
sure of  Rolando ;  S,  parieto-occipital  fissure. 


PREFACE. 


In  the  present  day  there  are  so  many  investigators  in  every  field  of  study, 
that  it  would  be  impossible  to  keep  pace  with  any  branch  of  it,  if  worked 
out  satisfactorily  and  to  its  full  extent,  unless  we  refreshed  our  ideas  from 
different  increasing  springs  of  knowledge,  and  thought  the  subject  over  and 
over  again  from  every  point  of  view.  This  applies,  perhaps,  more  to  medi- 
cine than  to  any  other  subject ;  for,  as  we  inquire  into  the  origin  of  human 
maladies,  new  features  continually  present  themselves,  and  new  mysteries  to 
be  solved  continually  arise. 

The  views  I  have  here  advanced  are  the  results  of  notes  and  observations 
carefully  recorded  by  me,  and  extending  over  a  period  of  many  years.  Tn 
most  of  the  cases  which  have  formed  the  groundwork  of  the  present  task,  I 
have  had  ample  opportunities  of  watching  their  course  and  progress.  I 
have,  moreover,  rather  relied  on  the  investigation  of  facts,  as  presented  by 
the  record  of  cases,  than  trusted  to  plausible  theories.  It  is  on  actual  facts 
I  have  attempted  to  lay  the  basis  of  the  treatment  and  management  which 
appear  to  me  best  adapted  to  meet  the  varieties  and  peculiarities  of  headache. 
In  all  search  for  truth  facts  must  be  recognized,  however  they  appear  to 
contradict  an  apparently  secure  and  well-established  principle.  To  grasp 
the  general  conception  and  meaning  of  any  subject  in  which  the  operations 
of  nature  are  concerned,  and  from  which  a  reasonable  solution  is  expected, 
we  must  establish  the  conclusions  which  lead  up  to  principles  on  the  sure 
foundation  of  fact,  and  not,  like  the  French  philosopher,  think  it  so  much 
the  worse  for  the  facts  if  they  are  not  included  in  our  theory.  If  theory  is 
unsupported  by  fact,  our  views  and  opinions  entail  disastrous  consequences, 
and  any  line  of  argument  we  may  have  adopted  is  rendered  utterly  futile. 

I  may  here  remark  that  several  works  have  recently  issued  from  the  medical 
press  on  the  subject  of  headache,  teeming  with  interest  both  to  the  patient 
and  practitioner.  Headache  has  always  been  carefully  studied  in  its  clinical 
aspect,  but  the  recent  advance  of  physiological  knowledge,  as  derived  from 
experiment,  has  given  a  new  and  powerful  stimulus  to  the  study  of  the  diseases 
of  the  nervous  system.  Not  only  has  it  furnished  a  stimulus,  but  it  has  tended 
much  to  clear  up  our  impressions  as  to  the  pathology  of  diseased  conditions. 
The  recognition  of  perivascular  spaces  has  enabled  us  to  comprehend  how  the 
blood-supply  of  the  brain  may  vary  from  time  to  time.  These  modifications 
in  its  physical  consistency  do  not  impair  its  functional  activity,  but  promote 
the  growth  and  reconstruction  of  the  nervous  system,  which  is  undergoing 
incessant  change  and  regeneration.  By  means  of  these  spaces  the  vessels 
dilate  without  compressing  the  brain,  and  when  they  again  contract  the  soft 
structures  of  the  brain  are  sustained  by  the  effusion  of  lymph  without  any 
serious  consequences  ensuing. 

The  researches  of  physiologists  heretofore  had  stopped  short  at  the  cere- 
brum, and  only  comprised  the  deep-seated  ganglia  at  its  base;  but  the  recent 
investigations  of  Fritsch  and   Hitzig,  and  still  more  of  our  countryman, 

(5) 


6  PREFACE. 

Ferrier,  have  demonstrated  that  the  different  portions  of  each  convolution 
possess  special  functions.  Some  are  motor-centres,  and  others  are  centres  of 
sensation.  The  vast  additions  which  have  been  recently  made  to  our 
previous  knowledge  by  Dr.  Ferrier' s  experimental  researches  justify  us  in 
drawing  certain  definite  conclusions,  not  only  as  confirmatory  of  the  func- 
tions of  the  deeper  structures  of  the  brain,  but  of  the  convolutions  them- 
selves. By  applying  electricity  in  the  form  of  local  faradization  to  the 
cortical  substance  of  the  brain,  he  could  produce  at  will  an  intense  amount 
of  hypercemia,  increasing  the  quantity  of  blood  and  the  size  of  the  vessels ; 
and,  in  the  case  of  rabbits,  he  found  that  the  repeated  application  of  the 
electrodes  converted  the  cerebral  substance  into  a  condition  resembling 
fungus  hcematodes.  By  irritating  the  different  portions  of  the  hemispheres 
in  some  of  the  lower  animals,  he  could  excite  partial  or  general  convulsions, 
and  these  were  invariably  preceded  by  a  hyperaemic  state  of  the  cortical 
tissue.  These  experiments  bear  most  strikingly  on  that  state  of  nerve- 
tension  which  Dr.  Liveing  describes  as  leading  to  "nerve-storms,"  when  an 
explosive  discharge  takes  place  from  the  ganglionic  centres,  reducing  the 
tension  and  irritability  of  the  parts  involved,  while  lessening  the  hypergemia 
on  which  they  depend.  A  recognition  of  these  facts  is  essential  to  a  rightful 
comprehension  of  headache.  They  help  in  no  small  degree  to  explain  the 
intimate  relation  of  the  nerve  force  to  the  blood  supply. 

My  earnest  endeavor  throughout  the  book  has  been  to  make  it  practically 
useful.  I  have  adopted  the  division  of  headaches  into  several  varieties, 
which  may  possibly  seem  to  some  readers  to  involve  too  great  a  refinement ; 
but  on  full  consideration,  I  think  they  will  find  it  neither  unnecessary  nor 
frivolous.  The  diagnostic  features  which  distinguish  hypersemia  in  some  of 
its  forms  from  congestion  and  plethora,  are  somewhat  difficult  to  lay  down, 
but  we  are  most  likely  right  in  assuming  that  there  is  a  physiological  differ- 
ence. As  regards  the  origin  of  active  hypersemia,  if  we  see  the  subject 
dimly,  we  are  sure  that  its  active  form  does  not  always  depend  upon  the 
same  pathological  conditions.  The  cerebral  tissue  is  over-excited  and  stim- 
ulated by  increased  cardiac  action  in  the  one  case  of  hyperemia ;  and  in  the 
other,  the  hyperaemia  is  the  consequence  of  relaxation  of  the  vessels,  and 
vaso-motor  paresis.  All  the  states  depend  upon  an  enlargement  of  the  cap- 
illaries, either  with  increased  activity  of  the  general  circulation,  or  with 
obstructed  or  retarded  motion  of  the  blood  through  them.  Congestion,  in 
the  strict  sense  of  the  word,  would  seem  to  be  the  excessive  attraction  of 
blood  by  the  tissues,  rather  than  either  the  active  or  passive  form  of  hjqoer- 
aemia.  A  hvpersemic  state  of  the  brain,  when  long  kept  up,  leaves  the  organ 
weaker,  and  disposes  it  to  an  asthenic  form  of  congestion.  I  have  described 
passive  hypersemia  and  passive  congestion  under  separate  headings,  and 
although  they  are  in  many  points  identical,  I  wish  to  imply  by  the  latter  a 
decrease  in  the  circulating  power  of  longer  standing,  a  more  relaxed  condi- 
tion of  the  vessels,  and  a  greater  tendency  to  serous  exudation. 

I  must  here  express  my  indebtedness  to  Dr.  Herbert  Major,  the  Superin- 
tendent of  the  West  Riding  Asylum,  for  permission  to  copy  a  plate  of  his, 
which  gives  the  microscopic  appearances  of  the  cerebral  cells  of  the  convo- 
lutions. It  is  on  these  cells  that  cerebral  activity  depends.  I  also  have  to 
thank  Dr.  Lauder  Brunton,  F.  R.  S.,  for  a  copy  of  a  woodcut  which  renders 
very  intelligible  the  association  of  headache  with  disturbance  in  the  abdom- 
inal viscera. 

I  have  made  some  additions  to  this  edition,  which  I  trust  may  be  as  favor- 
ably received  by  the  profession  as  the  three  previous  editions. 


CONTENTS 


PAGE. 


General  Introduction 9 

CHAPTER  I. 
The  Headache  of  Cerebral  Anemia .     16 

CHAPTER  II. 
The  Headache  of  Cerebral  Hyperemia 31 

CHAPTER  HI. 
On  Sympthetic  Headache 44 

CHAPTER  IV. 
On  Dyspeptic  or  Bilious  Headache 50 

CHAPTER  V. 
On  Congestive  Headache 56 

CHAPTER  VI. 

On  Headache  from  Plethora  and  Increased  Vascular  Action  .    .    61 

CHAPTER  VII. 
On  Headache  from  Exhaustion,  or  from  some  Peculiar  Change  in 
the  Cerebral  Tissue — Nervous  Headache 64 

CHAPTER  VIII. 

On  Nervo-Hyper^mic  Headache 82 

CHAPTER  IX. 

On  ToXiEMic  Headache 85 

CHAPTER  X. 
On  Arthritic  or  Gouty  Headache 94 

CHAPTER  XI. 
On  Rheumatic  Headache 97 

CHAPTER  XII. 

On  Headache  from  Affections  of  the  Periosteum 99 

CHAPTER  XIII. 
On  Organic  or  Structural  Headache loi 

CHAPTER  XIV. 

On  Headaches  of  Advanced  Life 105 

CHAPTER  XV. 
On  Neuralgic  Headache 107 

CHAPTER  XVI. 
Headaches  OF  Childhood  AND  Early  Life 115 

(vii) 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/headachestheirnaOOdayw 


DAY 

ON 

HEADACHES 


GENERAL   INTRODUCTION. 

Preliminary  Remarks  on  the  Preponderance  of  Diseases  of  the  Nervous  System  at  the  Pres- 
ent Day — Source  of  the  Pain  in  Headache,  and  its  Common  Dependence  on  the  State  of 
the  Brain  and  Nerves — Definition  of  the  Term — Difficulties  in  Adapting  Suitable  Defini- 
tions to  Embrace  all  the  Varieties  of  Headache — State  of  the  Brain  in  Some  Cases  of 
Apoplexy  and  Simple  Concussion — Importance  of  Rest  in  the  Treatment  of  Headaches 
at  all  Periods  of  Life,  and  more  particularly  in  the  Young,  when  the  Growth  of  Mind  and 
Body  is  in  Active  Progress. 

Many  affections  of  the  brain  rather  manifest  themselves  in  impaired  func- 
tional activity  than  in  actual  pain  and  suffering.  Almost  any  change  in  the 
circulating  fluid,  whether  it  be  degraded  from  the  absorption  of  noxious 
ingredients,  or  impoverished  by  a  diminution  of  its  normal  constituents,  will 
give  rise  to  irritation  and  that  alterated  sensation  which  indicates  a  disturb- 
ance in  the  sensorium. 

The  most  typical  diseases  of  the  present  day  are  those  which  affect  the 
nervous  system,  and  we  need  not  travel  far  to  ascertain  the  causes  which 
produce  them.  The  strain  to  which  the  nervous  system  is  subjected  through 
the  requirements  of  modern  times,  renders  it  far  more  liable  to  disease  than 
formerly,  and  men  break  down  prematurely  from  overwork  and  the  want  of 
rest.  Every  branch  of  study  is  now  pushed  forward  with  a  vigor  unknovra 
to  our  ancestors,  and  the  young  child  is  expected  to  grapple  with  abstruse 
questions  which  a  few  years  ago  were  only  intended  for  the  advanced  scholar 
and  those  who  made  philosophy  their  peculiar  study.  The  microscope  with 
its  revelations,  the  electric  telegraph  which  brings  us  in  immediate  contact 
with  the  enterprise  and  movements  of  other  countries,  are  both  powerful 
factors  in  stimulating  the  brain  of  man  to  unusual  activity ;  the  conflicting 
theories  and  theological  controversies  that  have  sprung  out  of  the  discoveries 
which  geological  science  has  called  forth,  and  the  generally  increased  pace 
at  which  we  live,  have  all  tended  to  excite  and  exhaust  the  brain.  The  tide, 
having  once  set  in,  rolls  with  resistless  force,  and  the  question  may  be  reas- 
onably asked,  Where  will  the  waves  of  destruction  stop  ?  The  diseases  of 
the  nervous  system  threaten  to  be  the  diseases  of  the  future,  as  they  are  of 
the  present  day,  in  spite  of  any  restraint  which  men  can  put  upon  themselves. 
However  desirous  they  may  be  to  prevent  it,  they  are  helplessly  and  irresist- 
ibly drawn  into  the  contest,  to  struggle  on  and  survive,  or  to  fall  early  in  the 
combat.* 

*  This  matter  has  not  escaped  the  attention  of  observant  laymen.  "The  politician,  the 
professional  man,  the  merchant,  the  speculator — all  must  experience  that  strain  of  special 
faculties  in  the  direction  towards  special  objects,  out  of  which  comes  nervous  exhaustion, 
with  the  maladies  consequent  on  overstimulus  and  prolonged  fatigue.  Horace  is  a  sound 
pathologist  when  he  tells  us  that  after  Prometheus  had  stolen  fire  from  heaven,  a  cohort  of 
fevers,  unknown  before,  encamped   themselves  on   earth.      In  our  audacious  age  we  are 

I  (9) 


lO  HEADACHES. 

Before  civilization  had  arrived  at  its  present  high  state,  the  overwrought 
brain  was  confined  to  men  of  letters  and  laborious  students  in  the  solitary 
contemplation  of  human  knowledge.  Nervous  exhaustion  was  not  the  com- 
mon disorder  we  now  find  it,  and  physicians  were  nearly  silent  on  the  causes 
which  produced  it.  In  whatever  direction  a  man  now  turns  his  attention, 
he  is  sure  to  see  competitors  who  are  striving  for  the  same  prizes.  In  trade, 
in  commerce,  in  literature,  and  in  art,  it  is  ever  the  same — no  man  has  the 
field  to  himself.  But  the  professional  man  may  perhaps  be  singled  out  as 
the  chief  example  of  overstrained  exertion.  He  must  strain  every  faculty 
toward  the  special  object  he  is  studying,  and  dare  not  leave  it  till  he  has 
worked  it  out  to  the  minutest  detail.  If  he  does  quit  the  field,  failing  to 
discover  some  new  stratum,  he  is  followed  by  another,  who  digs  up  the  hid- 
den treasure  which  gives  a  name  or  builds  up  a  future.  His  thoughts  are 
ever  active  and  at  work,  and  the  brain  will  not  rest  unless  other  occupations 
are  found,  and  a  new  set  of  organs  are  called  into  play.  In  the  physical 
disorders  of  man  a  certain  set  of  muscles  require  rest,  Avhilst  another  set  are 
required  to  perform  their  lost  functions;  and  disease  imitates  this  in  the 
activity  of  certain  organs,  to  allow  the  worn-out  ones  to  recruit  themselves. 
Rest  from  thought  would  obviate  much  of  the  fatigue  and  exhaustion  of  the 
brain,  if  it  could  be  adequately  measured  and  carried  out ;  but  the  circum- 
stances of  life  generally  do  not  enable  a  man  to  avail  himself  of  that  change  of 
thought  and  occupation  which  would  be  a  safeguard  against  the  terrible  evils 
he  is  fostering. 

If  there  be  any  truth  in  this  argument,  it  is  not  surprising  that  the  com- 
plex and  delicate  structure  of  the  brain  and  nerves  should  fail  under  the 
continued  strain  and  this  struggle  for  existence  in  the  battle  of  life.  Every 
emotion,  every  perception,  and  every  action,  operate  through  this  vast 
machinery,  and  invest  it  Avith  an  importance  which  did  not  belong  to  it  forty 
years  ago,  when  the  atmosphere  of  thought  was  more  serene  and  tranquil. 
What  wonder,  then,  if  the  nervous  system  should  suddenly  or  prematurely 
give  way,  if  it  has  to  bear  a  load  every  day  which  at  one  time  only  emer- 
gency or  accident  put  upon  it !  Added  to  the  altered  circumstances  of 
modern  times,  care  and  anxiety  bring  their  oppressive  burden  to  bear  in 
greater  force,  increasing  the  susceptibility  of  the  nervous  framework,  and 
robbing 'it  of  much  of  its  power  of  resistance. 

Then,  too,  the  luxuries  of  a  larger  portion  of  mankind  have  increased, 
and  in  a  corresponding  ratio ;  and  nervous  prostration  is  the  penalty  we  pay 
for  our  indulgence.  The  sensual  pleasures  of  life,  which  make  such  inroads 
on  our  strength  and  powers  of  endurance,  are  alarming  to  contemplate,  in 
the  varied  forms  of  suffering  which  they  produce  in  return  for  a  passing 
gratification  or  an  idle  enjoyment.  Sustained  and  steady  work  are  not  the 
prevalent  features  of  our  present  life,  but  laborious  strain  and  tension,  fol- 
lowed by  brief  and  broken  periods  of  repose. 

A  continuity  of  causes  oftentimes  produces  the  same  results ;  and  we  see 
this  exemplified  in  headache,  as  well  as  in  many  other  diseases.  There  is 
first  the  influence  of  excitement,  and  over-stimulation  to  the  brain,  and  then 
the  influence  of  exhaustion.  When  both  act  in  concert,  how  rapid  is  the 
downfall !  I  hold  with  unshaken  fidelity  to  the  conviction  of  a  nerve  pre- 
ponderance in  these  headaches  which  eclipses  every  other.  We  cannot  set 
aside  its  attractive  power  to  implicate  the  vascular  tissues,  and  to  change  and 
modify  the  signs  and  symptoms  of  disease  in  every  texture  of  which  the  body 


always  stealing  new  fire,  and  swelling  the  cohort  of  fevers  with  new  recruits." — Miscellan- 
eous Prose  Woi'ks,  by  Edward  Bulwer,  Lord  Lytton,  1868,  vol.  iii.,  p.  108. 


GENERAL    INTRODUCTION.  II 

is  made  up ;  nor  the  rival  sway  it  exerts  in  corrupting  the  machinery  of  the 
whole  body,  and  accomplishing  the  destruction  of  the  vital  parts. 

In  attempting  to  classify  headaches  into  groups  and  varieties,  some  specu- 
lations are  necessarily  indulged  in  to  establish  conclusions  and  to  support 
principles ;  but  I  have  endeavored  to  place  fairly  before  the  reader  the  chief 
aspects  of  the  question,  and  to  weigh  carefully  in  the  scale  of  calculation  every 
collateral  sign  of  investigation,  that  fallacy  may  be  reduced  to  a  minimum, 
if  not  wholly  got  rid  of,  and  that  conviction  of  some  sort  may  be  gained. 

It  has  been  my  desire  to  consider  this  matter  in  a  broad  light.  Devotion 
to  any  view  or  idea  gives  it  an  ascendency  in  the  author's  mind;  and  by 
attaching  undue  importance  to  it,  he  may  be  led  into  error.  We  are  all,  in 
fact,  more  or  less  disposed  to  incline  to  one  side  or  the  other,  and  so  to 
entertain  a  prejudiced  view  of  things,  which  has  a  cramping  effect  in  the 
pursuit  of  a  study  like  practical  medicine.  The  mind  is  to  be  pitied  that 
extends  the  range  of  inquiry  no  further  than  the  sphere  of  its  own  special 
study,  for  in  this  way  knowledge  is  improperly  applied.  "Men's  thoughts," 
says  Lord  Bacon,  "are  much  according  to  their  inclination,  and  they  speak 
as  they  have  learned." 

In  the  disorders  we  are  about  to  consider  we  shall  deal  chiefly  with  those 
that  are  functional,  for  curable  headaches  cannot  be  strictly  classified  with 
morbid  states  of  the  brain.  And  yet  the  difficulty  is  as  real  as  it  is  hypo- 
thetical. Molecular  changes  may  take  place  in  the  cerebral  cells,  and  pro- 
duce symptoms  allied  to  organic  lesions,  having  no  show  of  difference 
except  in  their  transient  duration. 

The  subject  of  headache  is  of  manifest  importance,  because  it  claims  so 
many  sufferers,  and  is  surrounded  by  so  many  difficulties — the  pathology  is 
obscure,  the  diagnosis  perplexing,  the  remedies  uncertain.  Headache  is  a 
disorder  of  the  utmost  frequency,  and  yet  there  is  none  which  more  taxes 
the  experience  and  scientific  knowledge  of  the  physician,  or  requires  closer 
observation  in  elucidating  its  nature  and  removing  its  obscurity. 

The  habitual  sufferer  from  headache  allows  no  other  pain  to  compete  with 
it.  Whether  he  is  prostrated  by  its  agony,  or  has  recovered  from  a  recent 
attack,  he  is  persistent  in  his  statement  that  a  continuance  of  the  pain  would 
rob  him  of  all  pleasure  in  existence,  and  make  him  sigh  for  escape  by  death. 
The  aching  cerebral  mass  shut  up  in  its  bony  cavity  only  reveals  its  morbid 
condition  by  the  statements  of  the  sufferer ;  in  its  functional  derangement 
it  does  not  indicate  by  any  reliable  signs  whether  this  or  that  part  is  at  fault, 
as  in  disorders  of  the  abdominal  or  thoracic  organs ;  the  source  of  the  suffer- 
ing cannot  be  fixed  upon  and  removed,  as  a  decaying  tooth,  or  a  calculus  in 
the  bladder ;  but  it  goes  on,  and  we  are  too  often  left  in  doubt  whether  the 
suffering  has  originated  in  the  brain  itself,  or  in  some  other  organ  of  the 
body  from  reflex  irritation  and  sympathy.  Are  the  brain  and  its  vessels 
deficient  in  the  supply  of  blood  ?  Is  the  circulation  contributing  its  due 
supply  of  arterial  nourishment  ?  Or  is  it  in  excess,  and  are  its  vessels  over- 
loaded? These  perplexing  questions  constantly  present  themselves  for  set- 
tlement. The  same  symptoms  arise  when  very  opposite  conditions  prevail. 
The  delirium  of  scarlet  fever  is  not  the  delirimn  of  typhus,  although  they 
may  present  very  similar  features.  There  is  the  sleeplessness  of  anaemia  and 
of  congestion  ;  and  there  is  the  coma  of  bloodlessness  as  well  as  of  hyper- 
semia.  How  can  such  dangerous  conditions  as  these  be  treated  with  any 
chance  of  success  if  we  have  erred  in  the  interpretation  of  their  pathological 
associations,  or  ascribed  the  phenomena  to  a  state  of  the  brain  and  general 
system  which  does  not  exist  ? 

Bearing  in  mind,  then,  the  intricacy  of  the  subject,  and  the  ever-changing 


1 2  HEADACHES. 

circumstances  that  surround  us,  we  approach  the  discussion  of  a  disorder 
which  modern  habits  of  life  encourage  and  develop,  and  threaten  to  increase 
tenfold.  Our  system  of  railway  travelling  has  no  small  share  in  producing 
that  aching  of  nerves  within  the  brain,  which  robs  existence  of  enjoyment, 
and  interrupts  the  serenity  of  social  life,  and  which  too  often  drives  the 
pitiable  sufferer  to  the  brink  of  despair,  when  he  finds  no  relief  in  the  legit- 
imate resources  of  our  art.  In  clinging  to  any  nostrum  within  his  reach,  he 
increases  the  evil  which  is  to  render  his  life  heavy  and  wearisome,  and  to 
baffle  his  energies  and  labors  to  the  end. 

In  no  class  of  diseases  do  we  observe  better  examples  of  sy77ipathetic  pain 
than  in  headache.  Pain  originating  in  one  part  may  be  transferred  to 
another  and  weaker  part,  or  to  one  ready  to  take  on  the  morbid  impression 
of  pain.  This  communication  is  regulated  to  a  great  extent  by  the  irrita- 
bility or  nervous  susceptibility  of  the  patient. 

The  mere  idea  of  pain  is  enough  to  bring  on  actual  pain  in  some  persons ; 
and  the  mind  can  so  vivify  or  exaggerate  it  as  to  give  it  a  reality  through 
sensation.  The  sympathetic  pain  of  the  shoulder  from  hepatic  disease,  the 
pain  in  the  knee  from  hip-joint  disease,  and  the  pain  of  the  genito-crural 
nerve  from  calculus  in  the  kidney,  or  the  severe  pain  down  the  thigh  after 
the  removal  of  ovarian  tumors,  are  all  instances  of  reflected  pain.  The 
transference  of  pain  beyond  the  seat  of  its  production  is  an  interesting  fact 
in  physiology,  and  where  the  impressions  can  be  traced  along  a  set  of  nerves 
the  explanation  is  forthcoming.  It  is  this  communication  which  refers 
painful  sensations  to  a  distant  part  from  which  the  irritation  has  sprung,  till 
it  finally  appears  to  have  its  origin  in  that  part,  whilst  the  original  seat  of 
mischief  is  lost  sight  of  altogether. 

If,  then,  the  cause  of  some  headaches  is  traceable  to  a  morbid  sensation 
conveyed  along  a  nerve  by  sympathetic  action,  it  is  explanatory  of  some 
painful  feelings  in  the  head  and  face,  through  the  contact  of  certain  articles 
of  food,  and  intense  cold,  on  the  terminal  nerves  of  the  stomach.  Any  sud- 
den shock  of  grief  may  occasion  gastric  pain,  and  it  certainly  awakens 
fearful  headache  in  some  persons.  "Putting  aside,"  says  Dr.  Symonds, 
"for  the  present,  any  reference  to  the  patient's  feelings,  what  do  we  learn 
from  anatomical  considerations  as  to  the  probable  source  of  pain  within  the 
cranium  when  the  person  is  the  subject  of  headache  ?  It  does  not  appear  to 
be  in  the  nervous  matter,  whether  vesicular  or  tubular,  of  the  cerebral  hem- 
ispheres, or  of  the  cerebellum.  No  evidence  of  feeling  has  been  obtained 
by  vivisectors  till  they  approached  the  sensory  ganglia — the  thalami  optici 
and  corpora  quadrigemina.  But  these  are  the  centres  of  sensation  to  all 
parts  of  the  body  as  well  as  to  the  head.  All  analogy  must  further  look  for 
the  nerves  as  the  source  of  pain  (though  some  writers  are  hardy  enough  to 
doubt  the  necessity  of  nervous  matter  as  instrumental  in  sensation).  And 
what  are  the  nerves  ?  Numerous  as  are  the  nerves  which  come  out  of  the 
cranium,  there  are  on  a  superficial  view  very  few  that  go  into  it.  A  branch 
of  the  suboccipital  accompanies  the  vertebral  artery,  but  a  large  majority  of 
the  other  nerves,  destined  for  intracranial  purposes,  are  derived  from  the 
sympathetic.  These,  then,  are  the  nerves  which  are  of  the  chief  interest  to 
our  present  inquiry.  Nerves  of  this  class  accompany  bloodvessels,  and  when 
we  observe  the  large  amount  of  these  vessels,  the  brain  and  its  membranes 
being  more  liberally  supplied  with  blood  than  any  other  organ  (the  quantity 
being  computed  as  one-fifth  of  the  blood  of  the  whole  body),  we  might, 
without  searching  further,  feel  convinced  that  there  must  be  a  correspondent 
supply  of  ganglionic  nerves ;  but  the  minute  examination  of  modern  anato- 
mists has  tracked  them  in  great  abundance."* 

*■  Gulstonian  Lectures  on  Headache,  Medical  Times  and  Gazette,  1858. 


GENERAL    INTRODUCTION.  I  3 

By  the  term  headache,  we  mean  to  signify  pain  in  the  head,  accompanied 
with  intolerance  of  light  and  sound,  and  incapability  of  mental  exertion ; 
a  state,  from  whatever  cause  arising,  in  which  the  brain  is  temporarily  pros- 
trated and  disturbed,  in  proportion  to  the  cause  and  intensity  of  the  suffer- 
ing. Thus,  many  headaches  depend  primarily  on  a  disturbance  in  the  cere- 
bral structure,  on  a  loss  of  balance  in  the  relations  of  the  nervous  force  and 
vascular  supply,  or  on  some  intricate  phenomena  of  the  mind,  which  increase 
the  sensibility  of  the  brain,  and  disturb  its  functions.*  Then  follows  sym- 
pathetic disturbance  in  the  digestive  organs,  which,  reacting  on  the  brain, 
mcreases  all  the  symptoms  for  a  time;  but  soon,  from  the  process  having 
advanced  further,  or  from  some  change  ensuing  in  the  current  of  the  circu- 
lation, the  morbid  sensibility  of  the  brain  abates,  and  the  headache  vanishes. 

For  some  days  before  the  development  of  a  nervous  headache,  patients 
will  admit,  on  close  examination,  that  they  felt  easily  fatigued  without  any 
real  cause  ;  that  they  awoke  unrefreshed  in  the  morning,  with  a  feeling  of 
weight  over  the  eyes,  which  passed  away  after  breakfast ;  that  before  the 
close  of  the  day  they  were  unusually  tired,  and  felt  on  going  to  bed  some 
flatulence  and  indigestion,  with  dryness  of  the  mouth,  and  an  extraordinary 
degree  of  depression  and  weariness.  During  the  night,  or  the  following 
morning,  the  nervous  headache  is  developed,  and  after  that  the  altered  sen- 
sibility of  the  brain  and  the  arrest  in  the  powers  of  digestion  proceed  to- 
gether. Symptoms,  therefore,  which  appear  as  primarily  indicative  of 
disorder  in  the  stomach  and  intestines,  are  really  often  secondary,  or  sym- 
pathetic affections,  resulting  from  the  pre-existent  disorder  within  the  brain ; 
and  when  we  come  to  consider  the  varieties  of  headache,  we  shall  see  how 
this  disturbance  is  effected. 

The  conditions  which  produce  some  forms  of  headache  are  wrapped  in 
mystery,  and  we  are  carried  into  the  realms  of  speculation  to  explain  them. 
The  cranium  of  the  adult  is  air-tight  and  unyielding.  In  a  healthy  state 
the  brain  probably  undergoes  neither  dilation  nor  compression.  Neither 
the  contents  of  the  thorax,  nor  the  abdomen,  sustain  the  same  amount  of 
pressure  for  one  second ;  the  elasticity  of  their  walls  through  the  movements 
of  respiration  keeps  them  in  perpetual  activity,  and  the  blood-pressure  is 
continually  changing ;  but  the  case  of  the  cranium  is  altogether  different. 
Where  a  tumor  is  present,  or  lymph  or  blood  is  effused  into  the  brain,  there 
is  an  alteration  in  pressure,  and  the  brain  substance  is  displaced  by  the  en- 
croachment of  disease ;  but  if  pressure  arises  gradually,  the  brain  sometimes 
adapts  itself  to  the  changes  which  are  going  on.  In  some  cases  of  apoplexy 
the  effusion  has  been  so  rapid  and  extensive,  that  it  has  pressed  upon  the 
brain,  so  as  to  cause  symptoms  of  rapid  compression  and  death.  It  should, 
however,  be  borne  in  mind  that  the  phenomena  of  apoplexy  have  ensued 
where  nothing  but  a  disproportionate  amount  of  blood  has  been  seen  in  the 

*  "  The  headache,  a  very  frequent  symptom  in  all  cerebral  diseases,  is  very  difficult  to 
explain;  we  do  not  even  know  if  it  is  of  central  origin  (that  is,  if  it  originates  in  the  parts 
of  the  brain  where  irritation  causes  symptoms  of  pain  after  the  insensible  greater  hemi- 
spheres have  been  removed),  or  whether,  as  I  think  is  more  probable,  it  depends  on  irritation 
of  the  filaments  of  the  trigeminus  going  to  the  dura  mater.  The  great  sensitiveness  to  im- 
pressions on  the  senses  depends  on  the  increase  of  excitability,  caused  by  the  cerebral 
hypersemia,  on  the  hypersesthesia  of  those  portions  of  the  brain  through  which  peripheral 
irritations  are  perceived.  The  patients  do  not  exactly  feel,  see,  and  hear  more  sharply  than 
ordinarily,  but  they  are  annoyed  by  irritations  far  weaker  than  such  as  usually  annoy  them. 
Light  troubles  them  ;  a  slight  sound  or  an  insignificant  irritation  of  the  nerves  of  touch  ex- 
cites disagreeable  feelings.  Morbid  excitation  (which  must  not  be  identified  with  increased 
excitability)  of  the  same  central  parts  causes  the  dazzling  before  the  eyes,  seeing  sparks, 
roaring  and  buzzing  in  the  ears,  the  sensation  of  formication,  or  of  undefined  pain,  which 
are  not  induced  by  peripheral  irritation." — Niemeyer'' s  Practical  Medici7ie,yo\.  ii,  page  159. 


14  HEADACHES. 

vessels  and  sinuses  after  death,  without  any  rupture ;  but  then  the  vascular 
connection  that  exists  between  the  vessels  of  the  brain  and  those  that  ramify 
over  the  face  and  scalp  has  a  tendency  to  relieve  the  sudden  determination 
within  the  head.  The  balance  of  the  cerebral  circulation  is  interrupted  when 
the  arteries  are  nearly  empty,  for  then  the  veins  are  full,  and  oppression  is 
the  consequence.  If  arterial  tension  is  increased,  and  the  vessels  are  full  a 
state  of  exaltation  and  excitement  then  ensues,  tending  to  delirium  or  mania. 
There  is  no  exact  evidence  of  the  actual  change  that  takes  place  in  the 
cerebral  mass,  when  a  physical  disturbance  of  the  brain  and  nervous  centres 
is  caused  by  simple  concussion.  A  mere  confusion  of  ideas,  or  a  temporary 
lull  in  the  mental  process,  as  though  the  sufferer  had  just  awoke  from  sleep, 
and  had  not  yet  realized  the  external  world  around  him,  are  all  the  manifes- 
tations of  the  mischief.  I  apprehend  that  in  these  slight  cases  of  shock, 
when  recovery  is  early  and  permanent,  there  is  no  structural  or  molecular 
lesion ;  but  when  headache  and  congestion  of  the  cerebral  vessels  creep  on 
after  a  time,  then  we  may  calculate  with  almost  absolute  certainty  that  the 
force  of  the  circulation  through  the  bruised  organ  is  disturbed,  being  exces- 
sive in  some  parts,  and  scanty  in  others. 

If  the  delicate  structure  of  the  brain  is  susceptible  of  molecular  disturbance 
from  injury,  it  is  a  rational  inference  to  suppose  that  the  same  may  occur 
from  functional  disorder  and  preverted  nutrition,  when  they  have  been  of 
long  standing.  A  structural  lesion  at  the  base  of  the  brain  is  possible  where 
the  vascular  supply  is  the  greatest,  and  the  minute  filaments  of  the  pneumo- 
gastric  nerve  are  abundant,  as  they  spring  from  the  medulla  oblongata. 
Now,  in  concussion  of  the  brain  the  enlightened  surgeon,  in  his  treatment, 
relies  more  on  rest  and  the  exclusion  of  light  and  sound,  than  on  any  other 
method  of  cure.  He  knows  that  any  plan  which  does  not  include  these  in- 
structions is  futile  to  effect  recovery,  and  to  afford  the  brain  a  chance  of  re- 
gaining its  equilibrium.  If  it  is  not  allowed  a  long  season  of  repose,  and  strain 
and  exertion  are  put  upon  it  at  a  time  when  the  utmost  quietude  is  demanded, 
then  softening,  inflammation,  and  gradual  degeneration  are  established. 

The  brain  cannot  stand  still  like  a  monument,  and  maintain  its  integrity. 
If  there  is  no  repair,  then  there  is  degeneration  ;  the  morbid  condition,  in- 
stead of  subsiding,  slowly  advances,  and  the  rest,  of  which  sleep  is  the  most 
perfect  form,  cannot  bring  its  restorative  influence  into  operation  ;  the  nights 
are  disturbed  and  restless,  and  dismal  dreams  announce  that  the  morbid 
changes  are  still  in  progress.  Repair  proceeds  with  activity  in  persons  of 
adult  life,  when  growth  has  ceased  and  the  bodily  framework  is  stationary; 
but  in  children,  when  the  tissues  are  building  up,  and  the  changes  are  rapid 
in  all  the  organic  functions,  recovery  is  often  tedious,  defective,  and  uncer- 
tain. In  these  young  patients  a  shaking  of  the  cerebral  mass  has  laid  the 
foundation  of  confirmed  headache,  and  subsequently  of  organic  change  in 
the  structure  of  the  brain,  sometimes  leading  to  exudative  products  and  mor- 
bid growths.  Repair  is  one  of  the  most  beneficent  manifestations  of  the 
goodness  of  the  Creator :  by  the  sorrow  and  pain  which  nature  inflicts  for 
the  disobedience  of  our  acts,  and  the  violation  of  the  laws  which  she  has  in- 
stituted for  our  observance,  she  stays  the  progress  of  disease  and  injury,  per- 
mits the  restoration  of  the  wasted  tissues,  and,  by  a  period  of  calm  repose, 
evokes  that  growth  and  repair  which  obviates  permanent  harm,  and  furnishes 
the  conditions  requisite  for  the  restoration  of  perfect  functional  activity. 
I  have  adopted  the  following  classification  of  the  varieties  of  headache:* 

"  This  classification  differs  from  that  which  I  have  adopted  for  the  headaches  of  children, 
because  adults  are  liable  to  some  forms  of  headache  which  do  not  belong  to  early  life. 


GENERAL    INTRODUCTION. 


15 


Headaches  depending  on  Causes  within  the  Brain — Intracerebral  Headaches. 

1.  The  Headache  of  Cerebral  Anemia. 

2.  The  Headache  of  Cerebral  Hyper^emia. 

3.  Sympathetic  Headache. 

4.  Dyspeptic  or  Bilious  Headache  (known  also  as  Sick  Headache). 

5.  {a)  Headache  from  Cerebral  Congestion,  or  Congestive  Headache. 
\b\  Headache  from  Plethora  and  Increased  Vascular  Action, 

6.  Headache  from  Exhaustion,  or  from  some  Peculiar  Change  in  the 

Cerebral  Tissue — Nervous  Headache.* 

7.  Nervo-hyper^mic  Headache. 

8.  Arthritic  or  Gouty  Headache. 

9.  Toxemic  Headache. 

10.  Organic  or  Structural  Headache. 

11.  Headaches  of  Advanced  Life. 

Headaches  depending  on  Causes  External  to  the  Brain — Extracerebral. 

1.  RheuxMatic  Headache. 

2.  Headache  from  Affection  of  tpie  Periosteum. 

3.  Neuralgic  Headache. 

Headaches  of  Childhood  and  Early  Life. 


THE   BASE    OF   THE   BRAIN   (fROM   HIRSCHFIELD    AND    LEVEILLe). 


I. 

Longitudinal  fissure. 

12 

Locus  perforatus  posticus. 

23 

Pneumogastric  nerve. 

2. 

Anterior  lobes  of  cerebrum. 

13 

Fifth  nerve. 

24 

Lateral  tract. 

3 

Olfactory  bulb. 

14 

Crus  cerebri. 

25 

Spinal  accessory  nerve. 

4- 

Lamina  cinerea. 

15 

Sixth  nerve. 

26. 

Digastric  lobe. 

S- 

Fissure  of  Sylvius. 

16 

Pons  Varolii. 

27 

Hypoglossal  nerve. 

6. 

Locus  perforatus  anticus. 

17- 

Portio  dura  of  seventh. 

28 

Cerebellum. 

7- 

Optic  commissure. 

18 

Middle  lobe  of  cerebrum. 

29 

Amygdala. 

8. 

Tuber   cinereum  and  infundi- 

19. 

Portio  mollis  of  seventh. 

3°- 

Slender  lobe. 

bulum. 

20 

Anterior  pyramid. 

31- 

Posterior  lobe  of  cerebrum. 

9- 

Third  nerve. 

21. 

Glosso-pharyngeal  nerve. 

32. 

Posterior  inferior  lobe. 

10. 

Corpus  albicans. 

22 

Olivary  body. 

33- 

Inferior  vermiform  process. 

II. 

Fourth  nerve. 



*  This  variety  of  headache  is  also  familiarly  known  as  sick  headache,  s^nd  it  is  so  termed 
by  some  authors ;  but  the  stomach  here  is  only  secondarily  affected. 


CHAPTER  I. 

THE  HEADACHE  OF  CEREBRAL  ANAEMIA. 

Physiology'  of  the  Cerebral  Circulation — Effect  of  the  Cerebro-spinal  Fluid  in  Influencing 
the  Circulation — Perivascular  Spaces — Cerebral  Ansemia  and  the  Sources  of  Blood  Supply 
through  the  Circle  of  Willis — Relation  of  Anaemia  to  Coma — State  of  the  Brain  in  Sleep 
— Experiments  of  Mr.  Durham — Physiological  Considerations  and  Conclusions — Symp- 
toms and  Diagnosis — Prognosis  and  Treatment — Physiological  Action  of  Alcohol  in 
Cerebral  Anasmia,  and  its  general  Effects  and  Consequences  on  the  Animal  Economy. 

Cerebral  Circulation. — Before  we  can  comprehend  fairly  what  is  nervous 
pain,  it  behooves  us  to  glance  at  the  peculiarities  of  the  cerebral  circulation, 
and  the  relationship  existing  between  the  nerves  and  bloodvessels. 

In  a  young  child,  with  its  open  and  elastic  fontanels,  the  amount  of  blood 
within  the  cranium  is  subject  to  great  variation,  because  the  skull  is  not  quite 
closed  by  bone,  and  the  cerebral  circulation  is  obedient  to  the  same  laws  as 
regulate  the  circulation  in  the  rest  of  the  body.  In  adults,  as  we  have  seen, 
when  the  ossification  of  the  skull  is  complete,  and  the  pressure  of  the  atmos- 
phere on  the  brain  no  longer  exists,  the  variation  in  the  contents  of  the 
cerebral  vessels  is  relatively  diminished ;  but  the  ventricles  and  subarach- 
noidean  fluid  keep  up  a  tolerably  uniform  pressure ;  and  where  the  cerebral 
substance  is  diminished  in  volume  from  any  cause,  the  fluids  and  blood  in 
the  vessels  prevent  that  difference  from  taking  place  which  is  so  common  in 
the  other  great  cavities  of  the  body.* 

The  experiments  of  Dr.  Burrows  and  others  prove  that  the  quantity  of 
blood  within  the  cranium  is  subject  to  considerable  variation,  and  conse- 
quently the  pressure  exerted  on  the  nervous  structure  would  be  considerable 
also  if  it  were  not  for  lym.ph  arrangements  within  the  encephalon.  Dr. 
Symonds  and  Mr.  Mitchell  Clarkef  conducted  some  careful  experiments 
which  confirmed  those  of  Dr.  Burrows,  who  proved  that  gravitation  affected 
the  quantity  of  blood  in  the  brain.  These  gentlemen  selected  three  rabbits 
— one  rabbit  was  suspended  by  the  hind-legs,  another  was  suspended  by  the 
ears  and  forelegs,  and  a  third  was  kept  in  a  horizontal  position.     "The  two 

*  "  There  can  be  no  doubt  that  the  most  important  influence  modifying  the  amount  of 
blood  in  the  brain  is  the  fulness  of  the  ventricles  and  other  cavities  of  the  subarachnoid 
spaces,  and  of  the  l)'mphatic  '  spaces '  or  sheaths  surrounding  the  cerebral  bloodvessels,  all 
of  which  spaces  contain  a  watery  fluid  identical  with  the  cerebro-spinal  fluid,  and  all  com- 
municate with  one  another.  Their  fulness,  as  said  above,  holds  a  precisely  converse  relation 
to  the  amount  of  blood  in  the  brain,  a  fact  which  has  Iseen  established 'with  regard  to  the 
perivascular  spaces  by  exact  measurements,  it  having  been  found  by  Golgi  that  they  are 
larger  in  all  conditions  of  the  brain  accompanied  by  anaemia,  and  smaller  in  hypersemic 
conditions." — Jones  e?=  Sieveking's  PatJiological  Anatomy,  by  Dr.  Payne,  p.  254. 

"  In  almost  all  autopsies  it  may  be  seen  that  the  amount  of  blood  contained  in  the  vessels 
and  the  amount  of  cerebro-spinal  fluid  are  in  inverse  proportion ;  that  a  distension  of  the 
vessels  of  the  meninges  is  accompanied  by  a  decrease  of  arachnoid  fluid,  and  conversely 
that  when  the  vessels  are  less  full,  the  meshes  of  the  textus  cdlidosus  snbarachnoidealis  con- 
tain a  greater  amount  of  serum.  Only  when  the  brain  is  atrophied  do  we  find  oedema  of 
the  membranes  with  overfilling  of  the  vessels ;  and  only  when  an  effusion  of  blood,  a  tumor, 
or  a  collection  of  fluid  in  the  ventricles,  has  contracted  the  space  in  the  skull,  do  we  find, 
along  with  anaemia,  dryness  of  the  membranes  and  disappearance  of  the  sulci  between  the 
cerebral  convolutions." — A'iemeye7''s  Practical  Medicine,  vol.  ii,  p.  150. 

f  Symonds  on  Headache,  Medical  Times  and  Gazette,  April  3d,  1858,  p.  34. 

(16) 


THE    HEADACHE    OF    CEREBRAL   ANEMIA.  1/ 

suspended  rabbits  were  poisoned  with  prussic  acid  after  about  half  an  hour, 
their  positions  having  been  strictly  maintained.  The  post-mortem  exami- 
nation was  made  immediately,  and  with  the  bodies  kept  steadily  in  the  same 
position." 

The  rabbit  suspended  by  its  hind  legs  was  found  to  have  its  eyes  congested, 
and  the  tissues  of  the  head  and  neck  gorged  with  blood ;  but  the  substance 
of  the  spinal  cord,  and  the  lumbar  and  dorsal  regions  were  pallid,  the  bony 
tissue  of  the  cranium  and  the  meninges  were  highly  congested,  and  the 
puncta  vasculosa  in  the  cerebral  substance  were  numerous.  The  ventricles 
contained  no  fluid,  and  there  was  none  external  to  the  convolutions.  The 
rabbit  suspended  by  the  ears  and  fore-legs  was  found  to  have  its  head,  neck, 
and  back  exsanguine,  whilst  the  lumbar  region  was  full  of  blood.  No  serous 
fluid  was  found  in  the  ventricles,  or  between  the  convolutions.  The  brain 
and  membranes  were  as  blanched  as  those  of  an  animal  bled  to  death.  In 
the  third  rabbit,  not  suspended,  also  poisoned  by  prussic  acid,  and  examined 
in  the  horizontal  position,  there  was  an  equal  distribution  of  blood,  and 
nothing  remarkable  beyond  the  absence  of  cerebro-spinal  fluid  in  the  cranial 
or  vertebral  cavity. 

In  a  full-grown  and  strong  rabbit,  suspended  by  the  ears  and  fore-legs, 
death  occurred  in  an  hour;  another  strong  middle-sized  rabbit,  hung  up  by 
its  hind-legs  for  four  hours,  recovered  itself  almost  immediately,  and  began  to 
feed  heartily.  We  see  that  the  congestion  of  the  brain  and  membranes  pro- 
duced no  ill  effects  comparatively,  whilst  the  opposite  position  was  quick!  y  fatal. 

These  experiments  corroborate  what  we  know  of  the  rapid  congestion  of 
dependent  parts  after  death,  and  of  the  tendency  to  hypostatic  congestion 
of  the  lungs  and  brain  in  fever  and  other  exhausting  diseases. 

It  has  been  satisfactorily  demonstrated  by  the  experiment  of  Dr.  Burrows, 
A.  Durham,  Hilton,  Kussmaul,  and  Tenner,  and  other  observers,  that  there 
is  vascularity  of  the  encephalon  during  excitement  and  mental  strain  ;  while 
during  sleep  and  exhaustion  the  vessels  lose  their  turgidity,  and  the  brain  is 
pale  and  bloodless.  These  changes  are  owing  to  the  presence  of  the  cere- 
bro-spinal fluid,  on  which  Mr.  Hilton  has  laid  so  much  stress.  When  it  is 
in  excess  the  vascularity  is  slight,  and  when  it  is  diminished  the  turgescence 
is  increased  (Rest  and  Pain).  Not  only  is  there  a  relation  between  the  in- 
tracranial vascularity  and  the  cerebro-spinal  fluid,  but  there  are  channels  in 
the  substance  of  the  brain,  termed  by  Robin,  His,  and  Obersteiner,  "peri- 
vascular spaces,"  along  which  the  blood  vessels  travel ;  and  these  are  invested 
with  a  loose  sheath  of  connective  tissue,  within  which  is  found  a  watery 
fluid,  regarded  by  some  as  lymph.*  When  the  brain  is  active  the  vessels 
dilate,  and  the  fluid  is  absorbed,  without  causing  any  compression  of  the 
nervous  structure  ;  but  when  this  activity  has  subsided  the  vessels  undergo 
contraction,  and  the  space  between  them  and  the  perivascular  space  is  again 
filled  with  fluid. 

Cerebral  Ancemia. — In  order  to  approach  anything  like  an  explanation  of 
the  different  forms  of  headache,  we  must  arrive  at  some  definite  conclusions 
regarding  the  quantity  of  blood  within  the  brain,  and  howansemia  is  brought 
about  when  the  supply  is  deficient  and  its  quality  altered.  It  is  computed,  as 
we  have  before  noticed,  that  the  brain  receives  fully  one-fifth  of  the  whole  blood 
in  the  body  (Haller),  a  circumstance  which  irresistibly  betokens  its  immense 
vigor  and  activity,  and  connects  it  with  consciousness,  and  thought,  and 
feeling — in  fact,  with  all  the  higher  attributes  of  the  mind  of  man.'j'     In  no 

*rrey's  Histology,  by  Barker,  p.  577. 

f  "  In  the  performance  of  an  idea,  as  in  the  performance  of  a  movement,  there  is  a  retro- 


lb  HEADACHES. 

organ  of  the  body  is  it  more  essential  that  blood  should  be  freely  supplied 
than  to  the  brain,  if  its  functions  are  to  continue  active  and  energetic.  The 
immense  pre-eminence  assigned  to  it  as  the  mental  organ  seems  naturally  to 
require  an  abundant  vascular  supply;  for  mental  changes  and  nervous  waste 
are  perpetually  going  on,  and  under  the  influence  of  strong  emotion  or  ex- 
citement, products  are  removed  from  the  system  by  the  skin  and  kidneys  in 
excess  of  what  ordinarily  occurs,  especially  in  the  amount  of  phosphates 
excreted.  I  may  mention,  as  bearing  on  the  point,  the  case  of  a  gentleman 
sixty  years  of  age,  in  whom  the  symptoms  of  cerebral  anaemia  are  well 
marked.  The  urine  is  loaded  with  phosphates  when  the  head  is  confused, 
and  the  brain  is  over-fatigued ;  but  after  rest  and  repose  they  disappear,  and 
the  secretion  becomes  natural. 

In  the  brain  the  demand  for  healthy  blood  is  two-fold.  In  common  with 
all  the  tissues  of  the  body,  it  requires  a  due  supply  of  nutrient  material  for 
the  maintenance  of  its  structural  integrity  and  functional  efficiency,  but  a 
more  urgent  demand  is  for  the  oxygen  which  is  conveyed  by  the  h^moglo- 
bulin  of  the  red  corpuscles.  Oxygen  is  absolutely  necessary  for  the  evolu- 
tion of  nerve-force  in  all  its  forms.  It  is  the  absence  of  oxygen  from  the 
blood  in  the  cerebral  capillaries  which  causes  death  to  occur  in  cases  of  suf- 
focation in  three  or  four  minutes ;  and  consequently  it  is  plain  that  a  defi- 
ciency of  it  must  impair  the  activity  of  the  nerve-elements  of  the  brain. 

Whenever  the  red  corpuscles  with  their  constant  supply  of  oxygen  are  not 
passing  through  the  capilliaries  of  the  brain  in  sufficient  number,  we  have 
cerebral  anaemia.  This  may  be  due  to  the  state  of  the  blood  itself,  as  in 
anasmia  and  cachexia,  when  the  corpuscles  counted  by  the  method  of  Pro- 
fessor Hayem,  of  Paris,  may  be  reduced  to  less  than  half  their  proper  pro- 
portion. Or  the  blood  itself  may  be  of  due  composition,  but  virtual  cere- 
bral anaemia  may  arise  from  weak  action  of  the  heart,  functional  or  organic 
in  origin,  through  the  slow  transmission  of  blood  along  the  vessels.  Or, 
again,  the  cerebral  blood-vessels  may  be  diseased,  and  obstruct  the  passage 
of  the  blood  by  loss  of  elasticity,  or  actual  narrowing.  This  is  the  great 
cause  of  the  cerebral  anaemia  of  advanced  life. 

Deficiency  in  the  circulation  of  the  brain  will  gradually  enfeeble  the  mind, 
and  lower  all  the  functions  of  the  body.  We  may  witness  this  when  there 
is  any  drain  going  on  from  the  system,  as  in  haemorrhoids,  menorrhagia,  or 
profuse  leucorrhoea.  If  the  blood  is  wanting  in  certain  constituents,  or  is 
contaminated  by  the  presence  of  others  which  it  ought  not  to  possess,  then 
the  mental  faculties  are  clouded  and  depressed,  and  the  brain  indicates  dis- 
order. This  is  remarkably  well  exemplified  in  the  cachexia  of  syphilis,  and 
in  blood-poisoning  from  lead,  copper,  or  mercury.  The  persistent  use  of 
alkalies  has  an  equally  injurious  effect.  I  am  sure  I  have  seen  the  disposition 
to  cerebral  anaemia  accelerated  by  the  prolonged  use  of  alkalies  and  mer- 
curial pills,  which  some  people  take  to  excess  because  they  fancy  the  liver  is 
disordered,  and  the  brain  confused  in  consequence.  They  may  afford  relief 
for  a  time  by  relieving  the  torpor  of  the  internal  organs,  to  which  an  en- 
feebled circulation  tends,  but  the  system  invariably  fails  in  the  long  run. 
The  same  happens  in  the  acute  fevers,  which  break  up  and  destroy  the  red 
corpuscles,  and  rob  the  blood  of  its  chief  vital  properties.  When  the  sup- 
ply of  healthy  arterial  blood  is  sufficient,  and  the  cerebral  circulation  is 
stimulated  to  activity,  the  thoughts  are  quick  and  bright,  and  the  pleasure 

grade  metamorphosis  of  organic  elements ;  the  display  of  energy  is  at  the  cost  of  highly 
organized  matter,  which  undergoes  degeneration  or  passes  from  a  higher  to  a  lower  grade 
of  being;  and  the  final  retrograde  products  are,  so  far  as  is  at  present  known,  somewhat 
similar  in  muscle  and  nerve." — Alaudsley. 


THE    HEADACHE    OF    CEREBIiAL    ANEMIA.  1 9 

resulting  therefrom  is  uniform  and  consistent ;  but  when  the  flow  of  blood 
is  unusually  rapid,  and  the  vessels  are  distended  and  throbbing,  then  mental 
excitement  ensues,  and  a  disorderly  succession  of  perverted  thoughts  and 
exalted  intentions  arise,  which  are  all  created  by  a  disturbance  in  the  balance 
of  the  circulation. 

The  rush  of  blood  to  the  head,  which  some  people  feel  when  they  are  the 
subjects  of  cerebral  anaemia,  is  to  be  thus  explained  :  Emotion  or  sudden 
excitement  causes  the  arterial  circulation  to  become  quicker,  and  this  fills 
the  cerebral  vessels  too  suddenly  with  blood  for  the  brain  substance  to  bear 
it  with  composure ;  besides,  the  venous  circulation  is  slow,  and  unable  to 
respond  to  the  call  at  once. 

The  unconsciousness  which  accompanies  syncope,  or  fainting,  takes  place 
when  the  heart's  action  is  failing  or  feeble,  and  the  cerebral  functions  are  no 
longer  stimulated  by  the  usual  flow  of  arterial  blood.  When  animals  are 
bled  to  death,  or  a  ligature  is  placed  upou  the  common  carotid,  convulsions, 
or  anaemia  of  the  brain,  are  more  usual  sequences  than  congestion  or  inflam- 
mation of  the  lungs.  It  is  obvious  that  this  shutting  off  of  the  arterial 
current  from  the  brain,  resembles  in  the  effects  produced  the  symptoms  of 
an  apoplectic  clot,  or  the  obstruction  due  to  embolism.  The  surface  is 
pallid,  the  pulse  quick  and  small,  the  temperature  occasionally  rises  from  the 
irritation  induced,  and  the  muscular  relaxation  is  complete.  With  the  con- 
dition of  pallor,  arising  from  mere  deficiency  in  the  arterial  blood  supply, 
there  occur  headache,  loss  of  memory,  petulance  and  irritability  of  manner, 
and  indifference  to  all  those  subjects  which  ordinarily  possess  interest.  The 
brain  is  badly  nourished,  and  it  refuses  to  respond,  for  the  nerve-centres 
have  lost  their  tone.  The  patient  lies  exhausted  in  his  bed,  with  slow  and 
feeble  respiration,  and  dilated  pupils.  If  the  veins  are  full,  and  there  is  fear 
or  terror,  the  features  may  be  livid  and  cold  from  the  effect  on  the  sympa- 
thetic system,  and,  through  it,  on  the  ventricular  contractions  of  the  heart. 
The  pallor  of  the  eye  and  its  dead  calm  present  a  striking  contrast  to  the 
red  and  eager  eye  of  hyperaemia.  There  is  often  the  blank  waxen  look  of 
despair,  with  the  angles  of  the  mouth  drawn  down,  as  though  the  patient 
had  passed  days  together  in  solitary  grief.  He  is  restless,  unreasonable,  and 
fidgety,  and  moves  spasmodically  from  one  part  of  the  room  to  another, 
like  a  man  w^hose  mind  is  ill  at  ease,  and  stricken  with  remorse.  Now  he 
feels  his  pulse,  now  he  consults  his  tongue,  and  if  he  has  the  sensation  of 
numbness  or  cramp  in  his  legs  he  dreads  the  approach  of  paralysis.  If  his 
attention  is  directed  to  his  head,  as  the  possible  cause  of  his  discomfort,  he 
fears  the  approach  of  a  fit  of  apoplexy,  and  is  afraid  to  be  alone.  In  women 
the  condition  is  more  passive. 

To  keep  the  brain  and  the  mmd  m  proper  working  order  involves  other 
considerations;  it  demands  a  discipline  of  life  which  few  persons  can  or  will 
carry  out.  Their  ordinary  habits  are  provocative  of  change  in  the  nervous 
tissue,  through  the  stimulants  they  daily  consume,  or  the  laborious  life  they 
are  compelled  to  lead.  Mental  effort  is  incompatible  with  muscular  strain, 
and  if  both  are  attempted  at  the  same  time  the  supply  of  blood  to  the  brain 
will  not  be  maintained,  and  the  tissue  will  suffer  from  innutrition.  Local 
congestions  overloading  some  portions  of  the  cerebral  mass,  and  obstructing 
the  free  current  of  blood  to  other  portions,  may  be  the  beginning  of  that 
anaemia  which  is  so  frequently  the  starting-point  of  some  headaches.  I  re- 
pose here  on  the  rationality  of  a  theory  of  ill  health  and  disease,  which, 
beginning  in  ansemia  and  tardiness  of  circulation,  ends  by  a  series  of  conse- 
cutive changes  in  impurity  of  the  blood  itself.  A  vital  fluid  so  contaminated 
destroys  at  length  the  vigorous  action  of  the  various  excretory  organs  of  the 


20  HEADACHES. 

body,  heaping  upon  them  work  which  they  cannot  discharge,  and  leading 
to  morbid  changes  of  structure.  Recent  microscopical  research  has  fully 
demonstrated  the  exactness  and  certainty  of  the  lesions  in  paralysis,  and  an 
endless  variety  of  other  forms  of  disease,  when  no  alteration  is  visible  to  the 
naked  e)'e.  When  during  life  the  symptoms  appear  to  indicate  a  cerebral 
lesion,  no  disorganization  can  be  discovered  after  death — not  more  vascular- 
ity or  congestion,  we  are  sure,  than  is  constantly  present  in  many  degrees  of 
headache ;  yet  the  influence  of  the  circulation  upon  the  functions  of  the 
brain  demonstrates  that  a  deficiency  or  excess  of  blood  does  not  interfere 
with  or  arrest  the  respiratory  movements,  and  cause  convulsions  or  delirium. 
In  what  manner,  or  to  what  extent,  disturbance  is  excited  in  the  cerebral 
functions  by  pressure,  may  yet  be  a  question  to  determine;  but  it  is  certain 
that  a  deficient  supply  of  blood,  or  a  state  of  anaemia,  will  disorder  the  brain 
and  cause  derangement,  as  in  epilepsy,  when  the  arteries  are  so  affected  as 
to  lead  to  their  contraction ;  while  their  thickening  and  diminution,  as  in 
atheroma,  also  render  the  supply  of  blood  deficient,  and  by  robbing  the 
brain  of  its  proper  nourishment  lead  to  disease.  Hence  uncomplicated 
anaemia  of  the  brain,  involving  nothing  more  than  a  meagre  supply  of  blood 
to  an  organ  Avhich  demands  it  in  a  large  quantity,  is  a  common  and  frequent 
cause  of  headache.  With  this  anaemic  state  there  is  in  these  cases  a  cachec- 
tic condition  of  the  blood  circulating  through  the  vessels,  and  this  I  appre- 
hend is  a  constant  accompaniment  of  headache. 

As  a  cause  of  headache  this  pathological  change  is  one  of  great  import- 
ance, though  it  is  not  easy  to  determine  during  life  except  through  the 
symptoms  produced.  The  brain  presents  a  pallid  appearance,  and  is  of 
diminished  consistence,  whilst  the  red  spots  alluded  to  in  congestion  are 
fewer  in  number.  In  some  persons  I  have  known  a  headache  from  this 
cause  to  be  of  such  a  wearing  character,  and  so  continuous,  that  symptoms 
allied  to  insanity  have  been  present,  and  alarm  has  arisen  in  the  minds  of 
those  who  have  witnessed  the  sufferer.  Now,  as  congestion  results  from  the 
overloading  of  the  bloodvessels,  the  striking  feature  of  this  anaemic  condition 
is  both  an  excess  of  fluid  in  the  cavities  of  the  brain,  and  an  infiltration 
through  its  substance,  giving  rise  to  the  state  known  as  oedema,  and  causing 
actual  enlargement  and  flattening  out  of  the  convolutions  against  the  men- 
inges. This  is  by  no  means  an  uncommon  cause  of  irritation  of  the  brain 
and  severe  headache.  And  here  I  may  observe  in  passing,  that  some  path- 
ologists are  of  opinion  that  pain  in  the  head  is  a  positive  indication  that  the 
meninges  are  involved,  and  that  when  they  are  free  there  is  an  absence  of 
suffering.* 

In  order  tct-uadsj  to  understand  the  subject  of  anemia  and  hyperaemia,  it 
is  important  to  glance  at  the  circulation  of  the  vessels  at  the  base  of  the 
brain,  and  see  how  freely  they  are  united  at  their  sides  and  in  the  middle 
line.  The  vascular  supply  is  enormous,  and  nature  has  provided  a  free 
circulation  of  blood  through  the  brain,  notwithstanding  that  a  large  vessel 
might  be  obstructed  altogether.  I  think  the  pain  of  occipital  headache  is 
sometime,  induced  by  the  abundant  blood-supply,  for  the  basilar  artery 
formed  by  the  union  of  the  two  vertebral  arteries  supplies  half  the  encepha- 
lon  with  blood,  viz.,  the  medulla  oblongata,  the  pons,  the  cerebellum,  and 
the  posterior  third  of  the  cerebrum  (Ellis).  The  anterior  portion  of  the 
cerebrum  is  supplied  by  the  internal  carotid,  which  divides  into  the  anterior 
and  middle  cerebral,  and  the  posterior  communicating  artery.  Now  this 
difference  in  the  amount  of  blood-supply  helps  to  explain  the  cause  of  fron- 

*  See  the  chapter  on  Organic  Headache. 


THE    HEADACHE    OF    CEREBRAL   ANEMIA.  21 

tal  headache  by  the  fact  that  the  vertebral  and  carotid  circulations  are 
independent,  and  because  they  are  regulated  by  different  vasomotor 
influences. 

Of  the  state  of  the  circulation  generally  in  cerebral  anaemia  we  may 
observe  that  the  very  opposite  conditions  exist  to  those  present  in  hyper- 
semia,  where  the  vascular  supply  is  well  maintained  and  the  cerebral  cells 
are  active.  In  anaemia  the  heart's  impulse  is  weak,  and  the  sounds  are  short 
and  indistinct — the  area  of  dulness  being  sometimes  increased  from  dilata- 
tion of  the  ventricles;  or  there  may  be  fatty  degeneration  of  its  muscular 
structure ;  the  pulse  is  feeble  and  easily  compressible  from  the  unfilled  state 
of  the  arteries,  and  the  general  diminution  of  blood  in  the  vascular  system. 

I  shall  allude  further  on  to  local  hyperaemia — to  one  part  of  the  brain  be- 
ing more  full  of  blood  than  another.  In  cerebral  anaemia  there  is  the  same  un- 
equal distribution  of  blood,  one  portion  being  more  exsanguine  than  another 
(except  at  the  base  of  the  brain  in  the  so-called  circle  of  Willis  just  described), 
because  the  cerebral  arteries  have  no  communication  one  with  another,  and 
the  diff'erent  vascular  areas  are  distinct  and  independent.  On  a  little  reflec- 
tion it  becomes  at  once  evident  that  the  circulation  may  receive  a  check  in 
some  part  of  its  curious  bendings,  and  proceed  unhindered  in  others.  The 
different  areas  of  the  brain  being  irregularly  supplied  with  blood,  it  is  clear 
that  the  unequal  distribution  not  only  causes  headache  of  a  nervous  type,  but 
gives  rise  to  a  perverted  or  morbid  condition  of  the  emotions — to  melancholy 
and  suspicion,  to  distrust  and  apprehension.  And  it  also  fully  explains  the 
effect  of  posture  in  relieving  or  aggravating  cases  of  headache.  There  are 
persons  who,  when  suff"ering  from  agonizing  headache,  cannot  rest  their  head 
on  a  pillow,  for  even  a  moment,  without  the  face  becoming  flushed,  and  the 
brain  throbbing  to  the  verge  of  delirium ;  because  the  egress  of  blood  from 
the  overloaded  vessels  is  not  aided  by  gravitation,  and  an  excessive  supply 
is  maintained  by  the  recumbent  posture. 

Chronic  cerebral  anaemia,  and  the  headaches  that  result  from  it,  are  to  be 
regarded  with  anxiety  in  those  persons  whose  nervous  system  is  hereditarily 
weak,  and  whose  minds  are  vacillating  and  unsteady.  A  headache  of  thirty 
years'  continuance  is  apt  to  produce  permanent  change  in  the  temper  and 
feelings,  and  to  diminish  the  powers  of  the  mind.  The  fear  that  organic 
disease  should  be  developed  after  a  period  of  depression  which  has  succeeded 
to  pain  and  suff"ering,  through  irritation  of  the  membranes  and  nervous  cen- 
tres, is  a  natural  one,  particularly  if  hallucinations  are  present,  and  the 
patient  has  a  fixed  idea  that  he  has  sustained  injury  or  wrong. 

It  would  be  an  error  past  redemption  not  to  connect  physical  disease  with 
mental  disease.  How  often  does  not  the  first  induce  the  last?  Perverted 
sensation  eventually  implicates  the  action  of  the  cerebral  cells,  and  by  its 
agency  brings  about  irretrievable  mischief  in  the  structure  of  the  brain,  if 
not  disease  of  the  bloodvessels  themselves.  The  brain  assumes  an  altered 
appearance;  it  becomes  atrophied  and  sodden,  and  the  convolutions 
shrunken  and  undeveloped.  The  patient's  gait  and  wasting  motor  power  in 
the  lower  extremities  accompany  the  intellectual  decay,  and  he  readily 
succumbs  to  the  influences  of  intercurrent  disease.  Sleep  is  broken  and 
nutrition  is  further  checked,  for  the  unrested  brain  cannot  fulfill  its  func- 
tions, or  repair  the  waste  of  its  tissue.  Disturbed  dreams  supplant  repose, 
and  morbid  changes  pursue  their  downward  progress. 

In  hyperaemia  the  head  is  hot  and  the  cerebral  vessels  full,  and  the  func- 
tions of  the  brain  are  slow  and  torpid ;  in  anaemia  the  cerebral  organs  are 
irritable  and  excitable,  and  the  face  is  pale  and  the  pulse  weak;  in  both  the 
functional  activity  of  the  brain  is  disturbed.     In  the  first  case  there  are 


22  HEADACHES. 

sensorial  disturbances  with  exaltation,  such  as  ringing  in  the  ears,  or  flashes 
of  light;  in  the  latter,  diminution  of  sensorial  power.  Commonly,  however, 
there  is  noise  in  the  ears,  arising  either  from  some  peculiar  condition  of  the 
nervous  apparatus,  allied  to  debility,  or  to  neuralgia ;  or  it  may  possibly  be 
explained  from  the  partially  filled  carotid  on  the  petrous  portion  of  the 
temporal  bone. 

Long-continued  congestion,  in  which  inflammation  has  taken  no  part, 
deranges  the  connection  existing  between  the  nervous  and  vascular  systems, 
and  induces  minute  degenerative  changes  in  the  coats  of  the  smaller  cerebral 
vessels.  If  these  vessels  become  blocked  up  or  lose  their  elasticity,  the 
relationship  between  the  brain  and  the  tissues  is  destroyed,  and  there  ensues 
degraded  nutrition  in  the  proper  structure  of  the  brain.  In  congestion,  as 
well  as  in  inflammation,  the  exudation  of  serum  or  the  effusion  of  albumin- 
ous matter  takes  place,  separating  the  elements  of  nerve  structure  from  the 
capillary  network,  arresting  nutrition,  and  accelerating  decay. 

Mr.  Durham  has  conducted  some  interesting  experiments  to  prove  that  in 
sleep,  when  the  brain  is  at  rest,  it  is  angemic,  and  no  longer  requires  its  ac- 
customed arterial  stimulus. 

Hitherto  it  had  been  generally  supposed  that  the  brain  was  lulled  into 
quietude  during  sleep  by  an  overcharged  state  of  the  cerebral  vessels — that 
congestion  and  a  large  blood-supply  were  most  favorable  for  repose  and  rest ; 
but  the  facts  adduced  by  Mr.  Durham  proved  the  soundness  of  his  conclu- 
sions, and  they  have  since  received  the  testimony  of  other  competent  ob- 
servers.    Mr.  Durham  supports  his  views  by  the  following  experiment : 

"A  dog  having  been  thoroughly  chloroformed,  a  portion  of  bone  about 
as  large  as  a  shilling  was  removed  from  the  parietal  region  of  the  skull  by 
means  of  the  trephine,  and  the  subjacent  dura  mater  partially  cut  away. 
The  portion  of  brain  thus  exposed  seemed  inclined  to  rise  into  the  opening 
through  the  bone.  The  large  veins  over  the  surface  were  somewhat  dis- 
tended, and  the  smaller  vessels  of  the  pia  mater  seemed  full  of  dark-colored 
blood ;  no  manifest  difference  in  color  between  the  arteries  and  veins  could 
be  perceived.  The  longer  the  administration  of  the  chloroform  was  con- 
tinued, the  more  distended  did  the  veins  become.  As  the  effects  of  the 
chloroform  passed  off,  the  animal  sank  into  a  comparatively  natural  and 
healthy  sleep.  Corresponding  changes  took  place  in  the  appearance  of  the 
brain ;  its  surface  became  pale  and  sank  down  rather  below  the  level  of  the 
bone ;  the  veins  were  no  longer  distended  ;  a  few  small  vessels,  containing 
blood  of  arterial  hue,  could  be  distinctly  seen ;  and  many  which  had  be- 
fore appeared  congested,  and  full  of  dark  blood,  could  scarcely  be  distin- 
guished. After  a  time  the  animal  was  roused;  a  blush  seemed  to  start  over 
the  surface  of  the  brain,  which  again  rose  into  the  opening  through  the 
bone.  As  the  animal  was  more  and  more  excited,  the  pia  mater  became 
more  and  more  injected,  and  the  brain  substance  more  and  more  turgid  with 
blood.  The  surface  was  of  a  bright-red  color;  innumerable  vessels,  unseen 
while  sleep  continued,  were  now  everywhere  visible,  and  the  blood  seemed 
to  be  coursing  through  them  very  rapidly ;  the  veins,  like  the  arteries  and 
capillaries,  were  full  and  distended,  but  their  difference  of  color,  as  well  as 
their  size,  rendered  them  clearly  distinguishable.  After  a  short  time  the 
animal  was  fed,  and  again  allowed  to  sink  into  repose  ;  the  blood  vessels 
gradually  resumed  their  former  dimensions  and  appearance,  and  the  surface 
of  the  brain  became  pale  as  before.  The  animal  slept  in  a  perfectly  natural 
manner.  The  contrast  between  the  appearances  of  the  brain  during  its 
period  of  functional  activity,  and  during  its  state  of  repose  or  sleep,  was 
most  remarkable.     In  order,  however,  to  be  quite  sure  that  I  was  not  misled 


THE    HEADACHE    OF    CEREBRAL   AN.EMIA.  23 

by  fancy,  nor  )^et  by  faulty  memory,  but  that  the  difference  was  really  great, 
I  operated  on  two  animals,  and  kept  them  alternately  in  different  states. 
The  animals  being  placed  side  by  side,  the  appearance  in  the  two  cases  could 
be  satisfactorily  compared."* 

When  the  functions  of  an  organ  are  active  and  energetic  it  is  freely  sup- 
plied with  blood,  and  when  it  is  sluggish  and  anemic  it  receives  a  small 
amount  of  blood.  But  even  this  view  is  not  altogether  satisfactory,  and  v/e 
are  bound  to  concede  some  relationship  between  the  blood  and  the  tissues 
themselves.  There  is  an  attractive  force  between  them.  Some  organs  draw 
more  blood  towards  them  in  disease  than  is  the  case  with  others,  and  this  is 
well  shown  in  remittent  fevers  and  ague,  where  the  mere  contraction  or  di- 
latation of  the  bloodvessels  through  the  vasomotor  nerves  cannot  account 
for  it. 

The  diagnostic  symptoms  that  belong  to  the  cerebral  ansemia  are  those  we 
might  expect  to  arise  from  a  weakened  brain  circulation.  There  are  fits  of 
depression  and  lowness  of  spirits ;  and  yet  these  are  not  continual,  for  the 
patient  may  be  roused  to  a  renewal  of  his  accustomed  efforts,  and  temporar- 
ily forget  his  ailment  altogether,  if  it  has  not  assumed  a  serious  aspect. 
The  patient  is  fearful  and  timid,  and  has  a  general  dread  of  things  and  of 
circumstances  never  likely  to  happen  ;  he  is  over-anxious  to  put  his  worldly 
affairs  in  the  best  possible  security,  lest  illness  should  overtake  him  suddenly; 
and  he  would  like  to  make  such  stipulations  for  the  future  as  shall  overrule 
the  liberty  of  his  successors,  and  control  the  ever-changing  events  of  life. 
Sleeplessness  is  not  an  uncommon  symptom,  but  many  patients  pass  sound 
nights,  and  in  the  day-time  become  drowsy  and  fall  asleep  in  the  chair,  or 
whilst  traveling  in  a  train  ;  and  this,  according  to  my  experience,  is  most 
frequent  before  the  bxain  has  passed  into  the  condition  which  produces  ac- 
tual headache  and  overpowers  the  reason. 

The  pain  is  most  frequently  vertical ;  it  occupies  the  top  of  the  head, 
which  feels  hot  and  burning  to  the  hand.  The  pain  is  not  throbbing,  or 
bursting,  but  of  a  gnawing,  scraping  character.  It  may  be  also  frontal,  or 
occipital,  and  present  most  of  the  characters  of  nervous  headache.  The 
headache  of  intellectual  strain,  and  severe  gastric  disorder  from  over-indul- 
gence in  alcohol  and  high  living,  is  almost  invariably  frontal,  and  the  veins 
about  the  temples  and  forehead  are  full,  and  the  face  is  flushed.  In  anemic 
headache  there  are  noises  in  the  ears,  dizziness,  and  flashes  of  light  before 
the  eyes,  especially  where  losses  of  blood  have  taken  place,  and  there  is  pallor 
of  the  skin  and  lips.  Swooning  and  twitching  of  the  muscles  are  also 
common. f 

The  patient  does  not  resign  himself  so  completely  to  his  misery  in  this 
variety  of  headache;  and  in  the  earlier  stages  of  the  attack,  at  least,  he  is 
more  anxious  about  his  fate,  and  when  he  is  likely  to  be  well  again.  When 
the  attack  is  threatening  he  is  unusually  fidgety  and  exacting,  and  exhibits  a 
querulousness  which  is  most  trying  to  contend  with. 

The  tongue  is  furred  at  the  back,  if  the  pain  has  been  of  any  considerable 
duration,  and  there  is  flatulence,  nausea,  and  constipation.  The  colon  is 
loaded  and  torpid  from  deficient  muscular  contraction,  which  is  common  in 
all  forms  of  impaired  functional  activity  of  the  brain  ;  indeed,  the  one  often 
induces  the  other.  The  pupils  are  sometimes  dilated,  but  frequently  they 
are  of  medium  size,  and,  according  to  my  experience,  when  the  pain  is  ver- 
tical the  pupils  are  oftener  contracted,  a  symptom  which  I  attribute  to  men- 

*  Physiology  of  Sleep,  Guy's  Hospital  Reports,  vol.  vi.,  i860,  p.  153. 

f  See  Chapter  XII.,  on  Organic  Headache,  concerning  the  seat  and  character  of  the  pain. 


24  HEADACHES. 

ingeal  irritation.  The  ophthalmoscopic  signs  reveal  pallor  of  the  optic  disks 
and  dullness  of  the  choroid.  The  blood  vessels  of  the  retina  are  generally- 
thin  and  few,  and  the  optic  disk  is  of  a  pale  and  waxy-white  hue,  which  is 
common  to  an  impeded  circulation  through  the  brain,  and  to  anemic  con- 
ditions generally.  The  eyes  are  sunken  in  the  orbits,  and  the  pulse  is  slow, 
labored,  and  languid.  In  a  patient  recently  under  my  care  the  pulse  did  not 
exceed  fifty-four  beats  per  minute  during  the  continuance  of  the  headache 
and  exhaustion.  In  this  case  there  was  some  dilatation  of  the  left  ventricle 
and  enlargement  of  the  heart  chiefly  due  to  fatty  change.  In  the  majority 
of  cases  the  pulse  is  weak  and  small,  owing  to  the  unfilled  state  of  the  ar- 
teries, and  the  diminished  quantity  of  blood  throughout  the  vascular  system. 
Slight  pressure  obliterates  the  pulse  altogether,  and  sometimes  it  can  scarcely 
be  felt.  In  other  cases  the  pulse,  in  addition  to  being  small,  is  habitually 
rapid,  and  the  heart's  impulse  weak  and  jerking  against  the  thorax.  In  the 
case  of  a  parient  who  was  drained  from  menorrhagia,  the  pulse  averaged  120 
for  weeks  together;  the  skin  and  mucous  membranes  were  dreadfully 
blanched,  and  )'et  there  was  no  headache  to  speak  of,  and  no  cardiac  mur- 
mur whatever.  Occasionally  a  shooting  neuralgic  pain  was  referred  to  the 
right  eye  and  temple,  but  it  was  never  vertical,  and  the  severity  was  greatest 
some  months  before  admission  into  hospital,  when  the  hsemorrhage  became 
sudden  and  profuse. 

In  the  headache  of  cerebral  anaemia,  of  which  the  nervous  form  in  deli- 
cate women  is  a  good  example,  the  feet  and  hands  are  cold,  and  the  surface 
of  the  skin  generally  is  dry  and  often  gelid.  The  gloomy  thoughts  and 
wretchedness  incident  to  this  anaemic  state,  too  frequently  induce  a  desire 
for  alcoholic  stimulants,  which  slowly  steals  on,  and  the  patient,  who 
through  life  may  have  been  most  temperate,  may  resort  to  this  indulgence 
till  it  merges  into  a  miserable  habit,  and  destroys  the  power  of  digestion  by 
taking  away  every  remnant  of  appetite.  It  is  a  passion  hard  to  overcome, 
because  it  gives  temporary  relief  by  dilating  the  vessels  of  the  brain,  and 
increasing  the  force  of  the  heart's  contraction.  So  far  there  is  relief;  but 
when  this  effect  has  subsided  the  depression  is  all  the  greater,  and  the  head- 
ache is  increased  tenfold. 

As  to  prognosis,  recovery  is  certain  if  the  pain  is  due  to  curable  condi- 
tions, and  the  system  has  not  been  reduced  too  low.  We  observe  this  over 
and  over  again  in  young  women  who  are  exhausted  by  prolonged  lactation 
and  hard  work,  or  who  have  had  miscarriages,  or  been  drained  by  leucor- 
rhoea.  When  the  habits  of  life  can  be  changed,  and  the  patient  is  able  to 
avail  herself  of  rest  and  proper  hygienic  measures,  her  debility  and  head- 
ache gradually  pass  away,  as  the  brain  is  better  nourished.  If  the  condition 
is  incurable  and  complicated  with  organic  disease,  the  headache  will  persist ; 
and  instances  of  this  kind  are  to  be  seen  among  the  poor,  where  all  the  sur- 
roundings are  wretched  and  deplorable. 

Treatment. — With  respect  to  the  treatment  of  the  headache  of  cerebral 
anaemia  and  exhaustion,  it  is  obvious  that  this  must  depend  on  the  peculi- 
arities and  special  symptoms  of  each  individual  case.  In  addition  to  the 
distraction  and  pleasant  society  by  which  the  current  of  gloomy  thoughts 
should  be  turned  aside,  and  in  order  that  gleams  of  joy  may  break  upon  the 
patient's  path,  and  disperse  those  heavy  clouds  of  sadness  which  add  to  the 
depression  of  the  disease,  the  medical  treatment  consists  in  endeavoring  to 
restore  the  tone  and  quality  of  the  blood,  that  the  cerebral  tissue  may  be 
better  nourished.  The  cause  must  be  ascertained  and  removed  if  possible. 
Where  men  have  subjected  themselves  to  great  intellectual  strain,  rising 
early  and  going  to  bed  late,  there  will  be  no  chance  of  recovery  till  these 


THE    HEADACHE    OF    CEREBRAL   ANEMIA.  25 

habits  are  given  up.  Men  so  circumstanced  only  keep  themselves  going  by 
irregular  living,  and  a  too  free  use  of  stimulants.  If  with  this  high  pres- 
sure there  are  pecuniary  anxieties  and  heavy  responsibilities,  and  the  patient 
has  no  alternative  but  to  remain  at  his  post,  he  is  certain  to  break  down. 
Entire  cessation  from  work,  and  absolute  repose  and  quiet  for  a  few  months 
or  a  year,  have  restored  the  brain  and  enabled  the  patient  to  resume  his 
duties  in  moderation.  Discharges  of  all  kinds  should  receive  prompt 
attention,  as  in  menorrhagia  and  leucorrhoea;  and  derangement  in  the 
assimilative  functions  should  never  be  overlooked.  The  tonic  effects  of 
arsenic  are  invaluable  (Form.  7-8),  and  iodide  of  potassium  is  indicated  if 
there  is  a  syphilitic  taint;  in  fact  those  remedies  will  be  serviceable  which 
increase  vascular  tension,  and  accelerate  the  flow  of  blood  in  the  encepha- 
lon.  In  gouty  conditions,  colchicum  and  the  alkalies  will  be  useful  to 
remove  the  mate7-ies  morbi  and  the  product  of  tissue  metamorphosis.  If 
depression  should  threaten,  the  addition  of  carbonate  of  ammonia  will  be 
found  useful  (Form.  31-32). 

Opium  is  a  remedy  which,  when  given  in  small  doses,  increases  the  force 
of  the  heart,  and  produces  a  soothing  influence  on  the  system  generally. 
If  employed  in  combination  with  a  stomachic  or  aperient,  I  have  never 
known  it  to  do  harm;  but  if  pushed  to  narcotism,  it  loses  its  sustaining 
powers,  locks  up  secretion,  and  becomes  depressing.  I  have  given  it  with 
advantage  in  half-grain  doses,  with  three  grains  of  powdered  rhubarb,  at 
bedtime,  in  the  form  of  a  pill  (Form.  102).  It  has  composed  the  patient 
and  relieved  the  cerebral  discomfort.  By  restricting  the  wear  and  tear  of 
tissue,  it  increases  in  some  unexplained  manner  the  nutritive  processes,  and 
is  of  service  in  allaying  the  extreme  restlessness  and  disquietude  which  are 
attendant  on  the  anaemic  condition. 

Dr.  Anstie  remarks  that  the  soporific  effects  of  opium  are  not  the  most 
remarkable  on  the  system.  "In  the  countries  where  opium  is  indigenous, 
it  is  an  article  in  daily  use  with  the  great  majority  of  the  population,  by 
whom  it  is  employed  for  a  very  different  purpose  than  that  of  procuring 
sleep ;  in  fact,  as  a  powerful  and  rapidly  acting  stimulant.  .  .  .  When  the 
opium  acts  efficiently,  not  a  trace  of  narcosis  can  be  perceived ;  on  the 
contrary,  the  vital  powers  are  distinctly  raised."* 

The  ammonio-citrate  of  iron  is  one  of  the  best  haematics  and  blood- 
restorers  in  the  whole  Pharmacopoeia,  and  is  a  very  valuable  drug  in  com- 
bination with  the  bromides  of  potassium  or  ammonium,  when  it  cannot  be 
safely  administered  alone  (Form.  71).  But  the  sudden  filling  of  the  cere- 
bral vessels  is  always  to  be  kept  in  mind,  and  regarded  with  apprehension. 

Digitalis  is  another  remedy  to  be  relied  on  when  the  heart's  action  is 
weak;  it  appears  to  strengthen  the  contractions  of  the  ventricle,  and  to 
render  them  more  uniform  and  regular ;  hence  it  is  of  value  in  weakness  or 
dilatation  from  any  cause,  when  given  in  small  doses.  In  anaemia,  where 
the  blood-supply  to  the  brain  is  not  enough  for  the  purpose  of  nourishment, 
it  increases  arterial  tension,  and  thus  it  becomes  of  as  great  service  here  as 
it  is  detrimental  in  hyperaemic  conditions  and  where  the  arteries  are  changed 
from  atheromatous  disease.  Digitalis  is  of  no  use  in  anaemic  headache, 
except  for  the  eff"ect  it  may  have  on  the  circulation  through  the  heart  itself; 
a  slow  pulse,  which  is  commonly  attendant  on  this  condition,  contraindi- 
cates  the  use  of  digitalis.  I  do  not  think  an  irregular  pulse  altogether 
demands  its  discontinuance  if  it  does  not  depend  on  change  of  structure ; 
but  where  there  is  decided  intermission   I  should  hesitate  to  employ  it.     I 

*  Anstie,  On  Stimulants  and  Narcotics,  Philadelphia,  Blakiston,  1864, 
2 


26  HEADACHES. 

believe  that  its  good  effects  in  these  cases  are  often  obtained  by  combina- 
tion with  a  few  drops  of  spt.  chloroform  (Form.  49-50).  The  fresh  infusion 
is  the  best  preparation  (Form.  51),  and  next  to  this  I  prefer  the  powder, 
with  a  grain  of  sulphate  of  iron  (Form.  103).  In  giving  the  tincture  in 
these  cases,  it  is  well  to  commence  with  five -minim  doses,  and  gradually 
increase  it  to  one  drachm.  Both  experiment  and  observation  go  far  to 
prove  that  reduction  in  the  frequency  of  the  heart's  action  takes  place 
through  the  influence  it  exerts  on  the  pneumogastric,  whilst  it  also  has  some 
eff"ect  through  the  cardiac  ganglia  in  increasing  the  force  of  the  heart's  con- 
tractions, and  causing  arterial  tension.  In  this  way,  the  arteries  becoming 
fuller  and  acting  with  increased  energy,  the  blood  is  propelled  with  greater 
vigor  into  the  veins.     Tea,  coffee,  and  quinine  act  in  a  similar  way. 

Belladonna,  according  to  Dr.  J.  Harley,  is  another  heart  tonic,  though  it 
is  said  to  weaken  the  muscular  power  generally,  and  to  cause  confusion  of 
ideas,  headache,  giddiness,  and  singing  in  the  ears.*  It  therefore  requires 
to  be  used  with  caution,  and  I  should  not  be  disposed  to  include  it  among 
the  remedies  for  this  condition.  While  strychnia  dilates  the  spinal  blood- 
vessels, belladonna  does  the  same  for  the  cerebral  vessels;  but  it  seems  to 
me  that  as  it  increases  the  force  of  the  arterial  current,  it  may  be  profitably 
employed  in  some  cases  (Form,  52-104). 

I  have  seen  good  effects  follow  the  use  of  phosphorus  in  doses  (varying 
from  gr.  ^-^  to  -Jg-:  Form.  89),  daily  after  luncheon,  whilst  the  hypophos- 
phites  of  lime  and  soda  have  been  given  in  calumba  morning  and  evening 
(Form.  28). 

The  headache  of  cerebral  ansemia  is  said  by  Dr.  Smith  to  be  often  mis- 
taken for  the  passive  congestive  form,  and  to  occur  in  enfeebled  heart  power, 
and  enlargement  with  dilatation  and  fatty  degeneration.  "Nitrite  of  amyl 
will  relieve  the  intermediate  headache.  Let  the  patient  inhale  three  to  five 
drops  of  it  on  a  piece  of  cotton,  placed  within  one  nostril,  while  the  other 
is  held  closed,  "t  When  this  headache  is  associated  with  nervous  exhaustion, 
as  it  very  commonly  is,  he  recommends  a  combination  of  strychnia,  iron, 
and  gentian  (Form.  33). 

Vomiting,  swooning,  and  faintness  are  common  in  cerebral  anaemia,  and 
the  patient,  in  a  well-marked  condition,  cannot  remain  in  an  upright  posture 
without  risk  of  syncope ;  for  the  blood  falls  away  from  the  vessels,  and  the 
elasticity  of  the  arteries  not  being  brought  into  play,  favors  venous  stasis, 
because  the  vasomotor  system  is  relaxed,  and  the  heart's  action  is  conse- 
quently depressed.     But  even  then  there  is  another  difficulty  to  be  encoun- 

*  "  Harley  has  found  that  after  the  administration  of  a  moderate  dose  of  belladonna  the 
arteries  are  contracted ;  but  that  when  a  large  dose  is  given,  the  contraction  is  replaced  by 
dilatation.  The  primary  contraction  is  due  to  stimulation  of  the  sympathetic  system,  and 
the  subsequent  dilatation  to  the  exhaustion  resulting  from  the  previous  overstimulation."^ 

I  gave  one  grain  of  the  extract  to  a  patient  who  had  dysmenorrhcea,  in  the  form  of  a  pill 
three  times  a  day,  and  it  produced  severe  frontal  headache  and  dimness  of  vision,  so  that 
she  could  not  see  ordinary-sized  print ;  the  face  was  hot  and  flushed  of  a  crimson  hue,  and 
the  pupils  widely  dilated,  which  gave  her  a  squint  and  a  strange  staring  look.  There  was 
loss  of  appetite,  and  difficulty  in  swallowing  from  contraction  of  the  pharynx  ;  the  girl  was 
very  tremulous  and  agitated,  and  her  sleep  was  disturoed  and  broken  by  horrible  dreams. 
Although  she  only  took  three  pills  altogether  (one  daily  for  the  first  three  days),  the  toxic 
symptoms  did  not  pass  off  completely  till  the  ninth  day. 

1  On  a  Case  of  Diabetes  Insipidus  treated  by  Belladonna  and  Ergot,  by  W.  Murrell,  L.  R.  C.  P.,  British 
Medical  Journal,  January  ist,  1876,  p.  9. 

f  The  Therapeutic  Effects  of  Headache,  by  A.  A.  Smith,  M.  D.  A  Lecture  delivered  at 
the  Bellevue  Hospital  Medical  College.  London  Medical  Record,  September  15th,  1876, 
P-  392- 


THE    HEADACHE    OF    CEREBRAL   ANEMIA.  2/ 

tered,  and  this  is,  that  if  the  cerebral  vessels  are  too  excited,  and  filled  with 
blood,  the  nerve-centres  are  excited  also,  and  headache,  heat  of  scalp,  and 
extreme  discomfort  ensue.  I  have  known  the  pulse  run  up  from  50  to  84  in 
the  course  of  a  few  hours  when  tonics  have  been  attempted  too  soon,  or  the 
patient  has  brought  on  acute  indigestion  by  eating  a  heavy  meal.* 

There  are  two  means  of  acting  on  cerebral  anaemia — (i)  by  raising  the 
blood-pressure  generally,  in  which  the  brain  profits;  and  (2)  by  acting  on 
the  cerebral  vessels,  and  dilating  them  especially.  These  two  measures  may 
be  combined  with  advantage  in  many  cases. 

Alcohol. — Headaches  due  to  cerebral  anaemia  and  exhaustion  are  fre- 
quently relieved  by  the  moderate  use  of  stimulants.  A  little  champagne  or 
claret,  or  weak  brandy  and  water,  may  be  taken  with  the  meals  (but  not  at 
odd  times)  so  as  to  prop  up  the  system  with  artificial  strength.  When  taken 
in  moderation  it  dispels  the  feeling  of  fatigue  and  exhaustion,  and  increases 
the  tonicity  of  the  vascular  system;  but  when  the  habit  is  acquired  of  drink- 
ing to  excess  it  produces  incalculable  harm,  by  enfeebling  the  digestive 
power,  and  aggravating  the  headache  and  confusion.  The  gastric  juice, 
which  is  poured  out  in  additional  quantity,  becomes  less  responsive  to  the 
stimulus  which  invited  its  secretion,  and  in  place  of  it  viscid  mucus  and 
fermentative  products  arise.  The  more  concentrated  the  stimulant  the  more 
injurious  are  the  consequences  on  the  mucous  membrane.  The  hot  and 
burning  sensation  which  is  experienced  on  swallowing  a  full  potation  of 
brandy  is  due  to  the  action  of  the  alcohol  on  the  tissues,  the  mucous  mem- 
brane becoming  white  and  puckered  up.  Dr.  Lauder  Brunton  says  that  in 
common  with  hot  metal,  or  corrosive  sublimate,  it  coagulates  albumen,  and 
that  the  white  color  of  the  mouth  is  "no  doubt  due  to  the  precipitated 
albumen  on  the  surface  obscuring  the  red  color  which  the  circulating  blood 
imparts  to  the  tissues  beneath." 

The  influence  which  alcohol  exerts  on  the  mucous  membrane  of  the 
stomach  is  precisely  similar.  We  are  so  well  acquainted  with  the  gastric 
uneasiness  which  accompanies  the  dry  hot  mouth  of  a  previous  night's  de- 
bauch, that  a  general  conviction  among  the  public  has  arisen  that  the  state 
of  the  one  organ  is  the  index  of  the  other.  "When  the  stomach  is  empty 
its  mucous  membrane,  as  seen  through  a  gastric  fistula,  is  pale,  and  only 
covered  with  a  little  mucus.  If  a  little  alcohol  is  now  introduced,  the  blood- 
vessels of  the  mucous  membrane  dilate,  and  it  becomes  of  a  rosy-red  color; 
its  glands  begin  to  secrete  copiously,  beads  of  gastric  juice  stand  upon  its 
surface,  become  larger  and  larger,  until  they  can  no  longer  preserve  their 
form,  when  they  coalesce  and  run  down  together  in  a  little  stream,  "f  The 
very  opposite  condition  follows  a  large  dose ;  the  mucous  membrane  be- 
comes pale,  and  the  secretion  of  irritative  mucus  takes  the  place  of  the 
gastric  juice. 

This  leads  me  briefly  to  consider  the  utility  of  alcohol  as  a  therapeutic 

.  agent.     Overindulgence  in  alcohol  (alcoholism)  is  a  formidable  disease  01 

the  nervous  system.     In  its  early  stages  it  is  characterized  by  derangement 

*  I  would  here  express  my  obligation  to  Dr.  J.  Milner  Fothergill  for  much  information 
derived  from  reading  his  two  instructive  and  valuable  papers  on  "Cerebral  Anjemia "  and 
"  Cerebral  Hypersemia,"  in  the  fourth  and  fifth  volumes  of  the  West  Riding  Lunatic  Asylum 
Medical  Reports.  In  the  treatment  of  these  affections  I  have  freely  availed  myself  of  many 
hints  and  suggestions.  These  papers  will  amply  repay  attentive  study,  from  the  orderly 
manner  in  which  the  facts  are  marshalled,  and  the  physiological  reasoning  which  supports 
the  views  set  forth. 

f  The  Physiological  Action  of  Alcohol,  by  T.  Lauder  Brunton,  M.  D.,  F.  R.  S.,  in  The 
Practitioner,  January,  1876,  p.  61. 


28  HEADACHES. 

of  the  assimilative  functions,  as  dyspepsia,  nausea,  and  congestion  of  the 
liver;  and,  later  on,  by  failure  of  nutrition,  muscular  weakness,  diminished 
intellectual  force,  and  gradual  degeneration  of  the  nerve-centres  and  tissues 
of  the  body. 

When  alcohol  is  habitually  resorted  to  in  excess,  its  action  resembles  an 
overdose  of  opium,  chloroform,  or  ether,  and  these  direful  consequences  are 
due  to  the  impregnation  of  the  blood  with  a  large  percentage  of  the  poison- 
ous agent.  "  It  may  cause  the  corpuscles  to  run  too  closely  together,  and 
to  adhere  in  rolls,"  converting  their  clear  outline  into  an  "irregular  or  star- 
like edge,"  and  changing  "the  round  corpuscle  into  the  oval  form." 
These  changes  appear  to  be  due  to  the  action  of  the  spirit  in  extricating  the 
water  contamed  in  the  corpuscles.*  "It  may  fix  the  water  with  the  fibrin, 
and  thus  destroy  the  power  of  coagulation,  or  it  may  extract  the  water  so  de- 
terminately  as  to  produce  coagulation. "f 

Experimental  physiology  has  aided  us  immensely  in  explaining  the  action 
of  alcohol  on  the  nervous  system.  "  If  we  surround  a  living  nerve  (partially 
dissected  from  its  connections)  with  alcohol  of  a  certain  strength,  we  find 
that  it  becomes  paralyzed,  /.  e.,  incapable  of  transmitting  impressions 
through  its  affected  part ;  while  a  very  weak  mixture  of  alcohol  and  water  is 
incapable  of  producing  this  affect.  Similarly,  if  an  animal  absorb  into  his 
circulation  a  certain  quantity  of  alcohol  within  a  given  time,  the  nerve- 
centres  and  the  peripheral  nerves  become  (though  in  less  degree)  para- 
lyzed." |  This  experiment  forcibly  teaches  us  that  blood  so  charged  with 
alcohol  is  totally  unfitted  to  support  the  nervous  tissue  in  health;  "there  is, 
however,  a  co-operative  cause  of  no  small  importance,  namely,  it  has  been 
ascertained  by  the  researches  of  various  observers  that  the  impregnation  of 
the  blood  with  large  quantities  of  alcohol  interferes  with  its  absorption  of 
oxygen,"  1 1  and  lessens  the  oxidizing  power  of  the  red  corpuscles. §  A  mod- 
erate amount  of  alcohol,  by  dilating  the  minute  bloodvessels,  and  stimulat- 
ing the  action  of  the  heart,  is  a  remedy  in  cerebral  anaemia  not  to  be  lightly 
set  aside,  when  the  circulation  is  reduced  below  its  normal  activity ;  for,  by 
improving  digestion  through  its  action  upon  the  gastric  nerves,  it  enables 
food  to  be  digested  which  cannot  otherwise  be  assimilated,  whilst  it  furnishes 
in  itself  a  certain  amount  of  oxidizable  material,  and  is  in  so  far  a  form  of 
food ;  but  carried  beyond  a  certain  point,  it  reduces  nervous  control,  and  as 
doing  so  is  an  indication  of  evil  augury.  The  heart  beats  quicker,  and  as 
it  loses  force  in  proportion,  its  power  is  too  weakened  and  impaired  for  any 
prolonged  effort  or  exertion.  Some  cases  of  cerebral  anaemia,,  in  which 
headache  is  the  most  prominent  symptom,  have  yielded  to  a  moderate  use  of 
stimulants,  from  the  dilatation  of  the  vessels  and  the  better  supply  of  blood. 
The  slackened  tide  of  the  circulation  has  gained  a  new  impetus  and  vigor, 
and  all  the  functions  have  derived  additional  stimulus  to  ward  off  threaten- 
ing mischief;  but  taken  immoderately,  or  on  emergencies,  the  physical  dan- 
ger done  to  the  animal  economy  is  manifested  in  organic  deterioration,  and 
in  the  shrinking  and  alteration  of  the  nervous  texture.     To  these  succeed 

*  On  Alcohol,  a  course  of  six  Cantor  Lectures,  delivered  before  the  Society  of  Arts,  by 
B.  W.  Richardson,  M.  D.,  F.  R.  S.,  1875,  p.  45. 

J  Ibid.  p.  46. 

J  Reynolds's  System  of  Medicine,  Alcoholism,  vol.  ii,  p.  144,  by  F.  E.  Anstie,  M.  D.,  F. 
R.  C.  P. 

II  Ibid.  p.  145. 

§The  Physiological  Action  of  Alcohol,  by  T.  Lauder  Brunton,  M.  D.,  F.  R.  S.,  in  The 
Practitioner,  February,  1876,  p.  122. 


THE    HEADACHE    OF    CEREBRAL   AN/EMIA.  29 

muscular  weariness,  confusion  of  thought,  looseness  of  ideas,  and  irresolution 
of  purpose.  Heavy  dreams  and  restless  sleep  increase  the  headache.  As  the 
prostration  of  vital  energy  creeps  on,  the  mind  loses  its  grasp  of  recent 
events,  as  in  childhood,  into  which  it  may  be  said  to  pass  a  second  time, 
while  failing  speech  is  the  harbinger  of  a  general  paralysis  and  a  total  wreck 
of  all  that  was  formerly  so  compact  and  powerful. 

If  in  cerebral  anaemia  drink  is  too  much  indulged  in,  the  sufferer  wakes 
with  a  diffused  headache,  vertigo,  and  flashes  of  light  before  the  eyes.  He 
has  many  of  the  symptoms  which  herald  the  approach  of  intoxication ;  a 
mental  disquietude  takes  possession  of  him,  and  he  is  painfully  apprehensive 
of  danger  in  open  daylight,  and  exceedingly  nervous  about  his  state  of 
health.  His  whole  character  is  changed;  tears  are  shed  and  dried  up  in  a 
moment ;  his  face  becomes  blank  and  expressionless,  and  his  eyes  watery  and 
inflamed.  For  some  years  past  I  have  had  under  observation  a  case  of 
headache  from  cerebral  anaemia,  where  the  chief  symptoms  were  kept  up  by 
the  injudicious  use  of  alcohol.  The  deleterious  consequences  chiefly  showed 
themselves  in  disorder  of  the  gastro-intestinal  mucous  membrane,  while  on 
one  occasion  profuse  haemorrhage  from  the  stomach  and  bowels  took  place. 
These  symptoms  were  so  severe  that  ulceration  of  the  stomach  was  at  one 
period  suspected,  but  abstinence  from  all  stimulants,  and  a  milk  diet,  rap- 
idly improved  the  condition.  It  was  followed,  however,  by  a  relapse  on 
two  separate  occasions,  when  the  old  habits  were  resumed,  and  nausea  and 
bilious  attacks  were  of  common  occurrence.  Other  symptoms  supervened, 
indicating  nerve  degeneration  ;  a  tremor  of  the  lower  limbs,  and  unsteadi- 
ness of  gait,  similar  to  what  is  observed  in  delirium  tremens.*  The  face  was 
generally  pale  and  sallow,  but  it  would  flush  under  ordinary  conversation, 
and  the  pulse,  which  was  habitually  small  and  slow,  would  become  quick  and 
tremulous.  Then  ensued  the  most  painful  headache  and  confusion  of  ideas 
— to  use  the  patient's  own  phrase,  "  his  head  went  all  wrong,"  and  he  only 
obtained  relief  by  assuming  a  recumbent  posture  in  a  dark  and  quiet  room, 
and  sleeping  for  three  or  four  hours.  After  this  rest  he  would  sometimes 
wake  up  comparatively  well. 

The  amount  of  alcohol  weighed  by  the  standard  of  what  a  man  takes  to 
health  (when  all  the  excreting  organs  are  actively  performing  their  func- 
tions) is  no  criterion  of  his  capability  to  tolerate  it  in  disease.  In  the  latter 
case  elimination  is  repressed,  and  his  nerve-centres  are  the  special  organs  to 
bear  the  brunt  of  the  evil.  When  the  appetite  is  poor,  and  an  insufficient 
amount  of  nutriment  is  consumed,  the  alcohol  is  rapidly  absorbed  from  the 
walls  of  the  stomach,  and  the  liver  is  the  first  organ  to  undergo  structural 
change.  All  remedies  containing  alcohol  in  excess  lessen  the  excretion  of 
urea  and  carbonic  acid,  and  beerf  is  especially  a  compound  which  interferes 

*"  The  worst  sign  of  impending  nervous  change  is  muscular  instability,  irrespective  of  the 
will;  that  is  to  say,  an  involuntary  muscular  movement  whenever  the  will  is  off"  guard.  .  .  . 
In  the  motor  centres  of  the  nervous  organization  the  foreign  agent  is  creating  disturbance  of 
function.  The  fact  is  communicated  to  the  muscles  by  the  nervous  fibres,  and  the  active  in- 
voluntary start  of  the  lower  limbs  rouses  the  sleeper  in  alarm.  Ignorant  of  the  import  of 
these  messages  of  danger,  the  habituated  alcoholic  continues  too  frequently  his  way,  until  he 
finds  the  agitated  limbs  unsteady,  wanting  in  power  of  co-ordinated  movement." — Diseases 
of  Modern  Life,  by  B.  W.  Richardson,  M.  D.,  F.  R.  S.,  p.  265. 
■\  One  pint  of  beer  (20  ounces)  will  contain — 

Alcohol  I  ounce 

Extractives,  dextrin,  sugar 1. 2  "   (524  grains) 

Free  acid 25  grains 

Salts 13  grains 

— Practical  Hygiene,  by  Dr.  Parkes,  Philadelphia,  Blakiston,4th  Edition,  p.  257. 
"  One  ounce  of  alcohol  is  equivalent  to  two  fluid  ounces  of  brandy  (containing  50  per 


30  HEADACHES. 

with  the  elimination  of  fatty  and  nitrogenous  matters,  heaping  upon  the 
system  partially  oxidized  products,  which  provoke  gout  and  liver  disorder. 
Our  knowledge  of  the  action  of  alcohol  is  very  imperfect,  but  it  may  be 
said  to  be  absorbed  into  the  system  after  its  reception  into  the  blood,  escap- 
ing in  very  small  quantities  by  the  lungs,  the  skin,  the  kidneys,  and  the 
bowels ;  so  that  it  is  now  a  generally  received  opinion  that  a  considerable 
quantity  disappears  in  the  body.*  The  experiments  of  the  late  Dr.  Anstie, 
Thudichum,  Dupre,  Baudot,  and  others,  show  that  the  elimination  of  alco- 
hol is  very  trifling  through  the  kidneys.  Although  there  is  some  difference 
of  opinion  as  to  the  amount  excreted,  most  observers  are  tolerably  agreed 
that  it  is  very  small.  The  constant  consumption  of  large  quantities  of  alco- 
hol leads  to  the  accumulation  of  fat  in  the  system,  and  produces  degenera- 
tive diseases  of  a  fibroid  and  fatty  nature.  "The  brain  and  its  membranes, 
and  its  vessels,  suffer  early  and  principally ;  and  Kremiansky  has  produced 
haemorrhagic  meningitis  and  pathological  changes  in  the  brain  vessels  and 
membranes  in  dogs  by  giving  them  alcohol.  There  is  no  question  that  sev- 
eral brain  diseases,  including  some  cases  of  insanity,  are  produced  by  excess 
of  alcohol.  So,  also,  degenerative  changes  in  the  stomach,  liver,  lungs,  and 
probably  in  the  kidneys,  result  from  immoderate  use." — (Parkes.)|  Un- 
fortunately there  are  many  forms  of  bodily  weakness  and  mental  wretched- 
ness which  drive  the  sufferer  to  seek  stimulants,  not  only  from  the  gratifica- 
tion he  feels  in  the  indulgence,  but  to  drown  his  misery  in  excitement  and 
forgetfulness.  Among  the  diseases  which  impel  persons  to  drink,  nervous 
affections  and  periodical  losses  of  blood  are  the  most  frequent,  and  the  dose 
which  at  first  restores  the  nervous  system  to  its  healthy  standard  is  soon  car- 
ried beyond  reasonable  limits.  The  relief  furnished  by  alcohol  in  the 
misery  of  cerebral  anaemia  is  one  of  the  most  fertile  sources  of  drinking 
habits,  especially  among  women. 

cent,  of  alcohol),  or  to  five  ounces  of  the  strong  wines  (sherries,  etc.,  20  per  cent,  of  alco- 
hol), or  to  ten  ounces  of  the  weaker  wines  (claret  and  hocks,  10  per  cent,  of  alcohol),  or 
to  20  ounces  of  beer  (5  per  cent,  of  alcohol).  If  these  quantities  are  increased  one-half, 
1%  ounces  of  absolute  alcohol  will  be  taken,  and  the  limit  of  moderation  for  strong  men  is 
reached." — Ibid.,  p.  277. 

*  "  ^Mlen  only  one  fluid  ounce  of  absolute  alcohol  was  given,  none  could  be  detected  in 
the  urine.  We  found  that  in  a  strong  healthy  man,  accustomed  to  alcohol  in  moderation, 
the  quantity  given  in  twenty-four  hours  that  begins  to  produce  effects  which  can  be  consid- 
ered injurious  is  something  between  one  fluid  ounce  (:=  28.4  C.  C.)  and  two  fluid  ounces 
(=  56.8  C.  C).  The  eff"ects  which  can  then  be  detected  are  slight,  but  evident,  narcosis, 
lessening  of  appetite,  increased  rapidity  of  rise  in  the  action  of  the  heart,  greater  dilatation 
of  the  small  vessels  as  estimated  by  the  sphygmograph,  and  the  appearance  of  alcohol  in 
the  urine.  These  effects  manifestly  mark  the  entrance  of  that  stage  in  the  greater  degrees 
of  which  the  poisonous  effects  of  alcohol  become  manifest  to  all." — Ibid.  p.  277. 

t  "  j\Iy  friend.  Dr.  George  Johnson,  informs  me  that  out  of  200  patients  with  Bright's 
disease,  from  all  causes,  he  found  no  less  than  53  were  drunkards." — Quoted  from  Parkes's 
Practical  Hygietie,  4th  edition,  Philadelphia,  Blakiston,  p.  276. 


CHAPTER  II. 

THE  HEADACHE  OF  CEREBRAL  HYPEREMIA. 

General  and  Local  Causes — Active  and  Passive  Hyperjemia  of  the  Brain — Condition  of  the 
Heart  and  Arterial  System  in  some  Cases  of  Surgical  Pyrexia — Gouty  Hyperasmia — 
Active  Hyperaemia  sometimes  due  to  Structural  Delicacy  in  the  Walls  of  the  Blood- 
vessels— Connective  Tissue  Overgrowth  in  the  Brain — Nature  and  Causes  of  Passive 
Hyperaemia  or  Congestion — Anatomical  Changes  in  the  Vessels  and  Meninges — Symp- 
toms of  Hyperaemia — Symptoms  and  Pathology  of  Sunstroke — Effect  of  Bloodletting  and 
Cold  in  reducing  the  Temperature  of  Hyperpyrexia— Hypersemia  due  to  Intellectual 
Strain  and  Bodily  Exertion— Relation  of  the  Tissues  to  their  Blood-supply,  and  the 
Effect  of  an  increased  Blood-supply  upon  the  Growth  of  a  Part. 

Treatment — Occasional  Utility  of  Venesection — Value  of  Aconite,  Tartar  Emetic,  and 
Saline  Purgatives — Friedrichshalle  and  Hunyadi  Janos  Waters — Moderation  in  Diet  and 
Avoidance  of  Stimulants — Importance  of  Walking  Exercise  —  Effects  of  Bromide  of 
Potassium,  Opium,  and  Hydrate  of  Chloral  in  diminishing  Cerebral  Excitement  and 
relieving  Headache — Action  of  these  Sedatives  on  the  Nerve-cells — Ergot  of  Rye — 
Therapeutic  Effects  of  Cold,  and  its  Mode  of  Action — Utility  of  the  Ice  Cap  in  con- 
trolling Cerebral  Hyperaemia  and  Vascular  Excitement. 

When  an  increased  quantity  of  arterial  blood  passes  through  the  enceph- 
alic mass  it  constitutes  the  condition  known  as  cerebral  hyperaemia.  It  is 
obvious  that  the  veins  at  the  same  time  are  full  and  distended,  and  hence  a 
state  of  venous  congestion  is  established.  If  it  continues,  the  dilatation  is 
attended  with  a  retardation  of  the  blood-current  through  the  veins,  to 
which  succeeds  a  diminished  flow  through  the  arteries  also. 

It  will  be  pointed  out  in  another  chapter  that  there  are  no  more  common 
causes  of  congestive  or  hyperaemic  headache  than  overprolonged  thought 
and  too  great  mental  occupation.  When  the  mind  is  attentively  engaged 
on  any  special  line  of  abstruse  reasoning,  or  taken  up  with  care  and  anxiety 
about  worldly  affairs,  the  effect  of  this  concentrated  attention  is  to  dilate 
the  arterial  vessels,  and  to  admit  a  larger  quantity  of  blood  than  usual  to  the 
cerebral  cells,  by  which  they  are  overwhelmed.  "The  activity  of  an  organ 
is  in  strict  relation  to  its  blood-supply,  and  the  capacity  of  each  brain  from 
time  to  time,  not  as  compared  with  other  brains,  depends  upon  the  amount 
of  arterial  blood  passing  into  it.  Such  is  the  true  physiological  cerebral 
hyperaemia  of  brain  activity,  contrasted  with  the  anaemia  which  is  an  essen- 
tial factor  of  sleep.  As  sleep  comes  on  the  brain  falls,  becomes  paler,  and 
many  of  its  bloodvessels  that  could  be  recognized  during  the  waking  state 
become  indistinguishable.  When  consciousness  returns  in  the  act  of  awak- 
ing, the  process  is  reversed ;  the  brain  fills,  grows  ruddier,  and  the  vessels 
which  were  lost  sight  of  in  sleep  can  again  be  distinguished  by  their  enlarged 
calibre.  Such  is  the  difference  betwixt  the  conditions  of  sleeping  and  wak- 
ing— so  far  as  the  blood-supply  goes,  but  no  further."*  As  the  brains  of 
most  persons  are  kept  in  a  state  of  great  activity  at  the  present  day,  the 
vessels  are  habitually  full,  and  the  tissue  is  increased  in  vascularity.  This  is 
proved  to  be  essential  for  the  maintenance  of  their  healthy  functions,  and 
they  would  even  be  arrested  if  the  supply  of  arterial  blood  was  deficient. 

Cerebral  hypercBniia  as  a  morbid  state  is  a  frequent  cause  of  headache; 

*  Dr.  J.  Milner  Fothergill  on  Cerebral  Hyperaemia,  in  West  Riding  Lunatic  Asylum  Re- 
ports, 1875,  vol.  v.,  p.  172. 

(31) 


32  HEADACHES. 

especially  of  that  variety  in  which  the  nervous  substance  and  the  bloodvessels 
are  both  concerned.  The  brain  is  increased  in  volume,  and  presents  a 
turgid  appearance  when  it  is  superficially  examined.  The  small  red  points 
which  are  observed  when  the  brain  is  sliced  are  the  mouths  of  open  blood- 
vessels, and  in  some  hyperaemic  states  of  the  brain  they  exude  a  good  deal 
of  dark  blood,  as  where  death  has  resulted  from  bronchitis  and  whooping- 
cough,  or  from  fever,  and  organic  disease  of  the  heart  and  kidneys,  which 
have  induced  coma  and  stagnation  in  the  contents  of  the  venous  vessels.  A 
faint  reddish  or  pinkish  tint  of  the  cerebral  substance  is  not  uncommon  in 
the  case  of  children  who  die  of  convulsions  of  meningitis,  and  this  is  attribu- 
table more  frequently  to  the  same  pathological  change  than  to  actual  in- 
flammation and  the  products  that  arise  from  it.  This  condition  is,  I  believe, 
a  common  exciting  cause  of  headache.  It  leads  to  local  congestion  (partial 
hypereemia),  and  often  indicates  the  seat  of  suffering.  When  a  change  of 
this  character  is  present  in  a  well-marked  degree,  and  has  come  on  rapidly, 
death  may  take  place  from  severe  congestion  without  the  occurrence  of 
actual  hemorrhage,  or  comminution  of  the  brain. 

There  is  an  active  and  a  passive  hypergemia  of  the  brain — two  opposite 
conditions  due  to  separate  causes,  and  presenting  a  distinct  set  of  symptoms. 

In  the  active  form  the  arteries  contain  a  larger  quantity  of  blood  than 
usual.  Active  hyperaemia  of  the  brain  occurs  with  violent  action  of  the 
heart,  or  excitement  of  the  circulation,  from  fever  and  so  forth,  as  we  have 
already  seen.  If  the  nerves  are  healthy,  they  may  undergo  some  degree  of 
pressure  froni  distended  vessels  without  causing  pain  or  disturbance;  but  if 
they  are  oversensitive,  any  change  in  the  force  of  the  circulation  at  once 
distresses  them;  and  hence  it  happens  that  an  excited  action  of  the  heart 
from  running,  palpitation,  or  violent  coughing  in  pulmonary  disease,  aggra- 
vates the  nervous  suffering  if  long  continued.  But  this  by  no  means  can  be 
accepted  as  a  rule,  for  the  exertion  of  wrestling,  running,  and  active  gym- 
nastic sports,  which  subject  the  cerebral  vessels  to  extreme  pressure  from  the 
accumulation  of  blood  within  them,  does  not  cause  pain  and  suffering;  and 
we  can  only  infer  that  this  exemption  arises  from  a  healthy  condition  of  the 
nerves,,  unless  the  fulness  and  congestion  have  been  of  such  duration  that  a 
change  has  taken  place  in  them.  I  am  glad  to  be  supported  in  this  view  by 
so  able  an  authority  as  that  of  Dr.  Handheld  Jones,  who  observes  that  the 
effects  produced  by  cerebral  hyperemia  vary  according  to  the  condition  of 
the  nervous  centres,  and  that  when  the  organ  is  healthy,  a  moderate  hyper- 
aemia does  not  disorder  their  action,  but  that  in  weak  and  excitable  subjects 
the  excitement  may  be  very  great.* 

When  febrile  symptoms  follow  surgical  operations,  Ave  may  sometimes 
witness  high  temperature,  and  intense  excitement  of  the  arterial  system. 
There  is  tension  in  the  pulse,  a  tumultuous  and  rolling  action  of  the  heart, 
and  an  exaggeration  or  modification  of  its  sounds,  followed  in  some  fatal 
cases  by  the  deposition  of  fibrin  in  one  or  more  of  its  chambers.  An  inde- 
scribable weight  and  confusion  in  the  brain,  with  headache  and  dizziness,  are 
experienced,  which  are  more  rapidly  relieved  by  cold  to  the  head  than  by 
any  other  measure  with  which  I  am  acquainted;  except  in  some  cases  where 
venesection  is  so  far  to  be  credited  with  reducing  the  temperature,  that  it 
has  been  known  to  refuse  to  fall  till  bloodletting  was  practiced.  I  shall 
consider  this  more  fully  when  we  come  to  speak  of  the  treatment. 

This  form  of  hyperemia  is  witnessed  to  perfection  in  the  high  inflamma- 
tory fever  which  sometimes  succeeds  great  surgical  operations,  more  par- 

*0n  Functional  Nervous  Disorders,  Hypergemia  of  the  Brain,  1870,  p.  88. 


THE    HEADACHE    OF    CEREBRAL    HYPEREMIA.  33 

ticularly  in  young  full-blooded  persons,  who  are  not  emaciated  or  otherwise 
reduced  by  the  disease;  or  who  have  not  lost  sufficient  blood  at  the  time  of 
operation  to  control  excessive  reaction.  If  at  the  commencement  of  these 
symptoms  the  skin  is  dry  and  pungent,  the  pulse  is  generally  hard,  tense, 
and  rapid ;  the  conjunctivse  are  reddened,  the  carotid  arteries  beat  violently, 
and  the  jugular  veins  are  likewise  full  and  pulsating ;  the  heart's  action  is 
tumultuous,  and  strikes  vehemently  against  the  walls  of  the  thorax;  the 
sounds  are  muffled  and  run  together,  or  the  first  sound  is  soft  and  prolonged, 
both  at  apex  and  base — ^just  what  might  be  expected  from  the  alteration  in 
the  relative  proportions  of  the  blood-corpuscles,  and  the  rapidity  with  which 
the  organ  has  to  deal  with  the  obstruction  offered  by  the  deposition  of 
fibrinous  coagula  in  one  in  one  or  more  of  its  chambers.  With  this  state  of 
vascular  excitement  there  are  disturbances  of  sensibility,  which  partake  more 
of  an  irritating  than  of  a  painful  character.  There  is  throbbing  over  the 
forehead  and  vertex  of  the  head,  and  a  feeling  sometimes  of  contraction, 
and  at  others  of  bursting — I  have  heard  it  also  described  as  a  disagreeable  or 
nasty  sensation;  the  sight  is  dim,  and  the  patient  prefers  darkness  to  day- 
light; sleep  is  broken  and  disturbed  by  restless  dreams,  till  the  head  is 
cooler  and  the  temperature  reduced.  The  constitutional  symptoms  are  not 
so  alarming  when  the  skin  is  bathed  in  sweat  and  the  kidneys  are  acting 
freely,  for  then  the  tension  is  to  a  great  extent  taken  off  the  arterial  system, 
and  the  determination  of  blood  to  the  brain  is  lessened ;  the  pulse  is  more 
compressible,  the  confusion  of  ideas  is  mitigated,  but  the  face  may  assume  a 
purplish  flush,  and  the  lips  become  of  a  dark-livid  red.  In  cases  of  this 
character  the  injudicious  use  of  stimulants,  even  in  the  shape  of  hot  tea  or 
coffee,  aggravates  the  symptoms  of  cerebral  excitement,  and  increases  coagu- 
lation in  the  vessels,  till  they  are  on  the  point  of  rupture,  or  so  distended 
that  they  cannot  propel  their  contents;  and  at  last  induces  effusion  in 
the  neighborhood  of  the  large  vessels  at  the  base  of  the  brain,  with  a  torpid 
and  comatose  condition. 

Some  persons  of  a  sanguine  and  excitable  temperament  suffer  from  active 
hyperasmia,  or  determination  of  blood  to  the  head.  They  experience  sound 
health  till  something  ruffles  them,  or  opposes  their  plans,  and  then  it  is 
readily  induced  by  alcoholic  stimulants  and  high  feeding.  It  cannot  be 
said  that  there  is  too  large  a  quantity  of  blood  in  the  body ;  on  the  con- 
trary, the  predominance  of  the  nervous  over  the  vascular  element  renders  it 
probable  that  there  is  habitually  an  insufficient  supply  for  the  demands  of  an 
ouerstrained  nervous  system.  The  brain  in  these  cases  is  exposed  suddenly 
to  a  sort  of  deluge  ;  and  two  factors  are  concerned  in  the  mischief.  A  dis- 
turbed stomach  transmits  its  irritation  through  the  sympathetic  system  of  the 
brain,  already  overloaded  with  blood  ;  and  as  the  vasomotor  nerves  become 
relaxed,  a  further  increase  of  blood  overpowers  the  brain  in  consequence, 
apart  from  the  hyperasmia  which  the  increased  activity  of  the  systemic  cir- 
culation induces.  Persons  whose  digestive  organs  are  weak  and  sensitive, 
or  v/ho  sit  down  to  a  meal  agitated  and  disturbed,  soon  experience  discom- 
fort and  excitement ;  the  head  aches  violently,  and  the  face  flushes  scarlet, 
and  no  ease  can  be  obtained ;  the  temporal  arteries  throb,  and  the  pulse  is 
full  and  frequent.  Everything  that  is  taken  causes  nausea  and  vomiting,  and 
no  relief  is  forthcoming  till  a  few  leeches  are  applied  to  the  head,  or  the 
contents  of  the  intestine  are  washed  out  by  active  purgation.  Instances  of 
this  kind  occasionally  present  themselves  in  the  practice  of  our  profession. 
.When  the  headache  continues  severe,  and  the  intelligence  becomes  blunted, 
so  that  the  patient  can  scarcely  stand  or  walk,  a  moderate  bloodletting  or  a 
free  epistaxis  has  been  followed  by  immediate  relief,  and   the  cerebral  con- 


34  HEADACHES. 

gestion  has  disappeared.  If  no  revulsive  measures  have  been  resorted  to,  or 
the  loss  of  blood  has  not  occurred,  the  symptoms  of  active  congestion  and 
intravascular  pressure  may  be  converted  into  those  of  effusion  and  fatal  apo- 
plexy. 

Active  hypersemia  is  very  commonly  seen  among  men  who  have  passed 
the  meridian  of  life.  They  are  of  stout  configuration,  and  the  face  is  full 
and  florid ;  the  conjunctivae  are  injected,  and  the  pulse  is  firm  and  incom- 
pressible. They  easily  tire  and  become  breathless  on  exertion  if  they  at- 
tempt to  walk  at  a  moderate  pace,  or  ascend  a  hill,  which  is  one  reason  why 
sedentary  pursuits  or  actual  idleness  are  more  congenial  to  them  than  out- 
door occupation.  Such  men  as  these  need  be  endowed  with  immense 
energy  and  force  of  character  to  willingly  encounter  fatigue  and  determine 
to  live  abstemiously,  when  the  constitutional  diathesis  impels  them  in  a  di- 
rection which,  however  detrimental  to  their  health,  is  at  least  acceptable  to 
their  feelings.  The  ordinary  precautions  against  illness  are  disregarded  and 
set  aside,  and  the  patient  never  pauses  to  consider  that  his  mode  of  living 
is  injurious,  but  goes  on  in  the  same  course.  His  mental  condition  is  emi- 
nently characteristic.  However  amiable  he  may  be  by  nature,  irritability 
becomes  a  new  and  striking  feature  in  his  character,  surprising  his  most  in- 
timate associates,  and  those  who  have  known  him  best  through  life.  Tri- 
fling annoyances  vex  him  and  put  him  out,  and  he  bursts  into  fits  of  passion 
and  violence,  which  would  not  disturb  the  mind  of  a  man  in  health.  As 
soon  as  these  outbursts  of  passion  are  over,  the  mind  is  restored  to  reason 
and  reflection  ;  and,  as  he  finds  relief,  so  he  admits  the  weakness  that  over- 
took him.  He  is  what  is  called  low  at  times,  and  suffers  acutely  from 
throbbing  headache.  These  persons  have  lived  too  well  from  their  early 
manhood,  and  indulged  in  food  of  a  nitrogenous  character.  In  consequence 
of  this  stimulating  diet,  and  the  patient's  lethargy  and  inaction,  effete  mat- 
ters accumulate  in  the  blood,  and  throw  upon  the  kidneys  and  other  excre- 
tory organs  an  amount  of  labor  which  provokes  structural  change.  A  gouty 
element  is  the  disturbing  foe  when  more  visible  indications  are  wanting; 
and  one  of  the  first  morbid  changes  to  arise  is  a  hyperaemic  state  of  the  kid- 
ney from  the  excessive  supply  of  blood,  so  that  the  organ  is  no  longer  able 
to  completely  discharge  its  functions.  Then  follow  spasm  of  the  arterioles, 
and  that  rise  in  blood-pressure  which  leads  to  hypertrophy  of  the  left  ventri- 
cle, and  the  transmission  of  blood  to  the  brain  in  greater  force.  As,  there- 
fore, the  heart  increases  in  size  from  the  additional  duty  it  is  called  upon  to 
discharge,  so  the  natural  tissues  of  the  kidney  become  diseased,  and  the  ves- 
sels of  the  brain  atheromatous  and  liable  to  rupture  from  the  distension  to 
which  they  are  subject. 

The  condition  of  cerebral  hyperaemia  is  denoted  in  some  persons  (espec- 
ially men  of  full  or  gouty  habit  who  are  approaching  sixty  years  of  age),  by 
the  face  being  florid,  and  the  capillaries  full  and  distended.  Not  unfrequently 
the  nose  is  marked  with  acne  rosacea,  from  the  too  free  use  of  stimulants 
and  overindulgence.  There  are  noises  in  the  ears,  and  the  head  is  confused 
and  aches  fearfully — it  is  a  deepseated  pain,  as  though  a  nail  was  being  driven 
into  it ;  and  the  pulse  is  full,  tense,  and  hard — it  is  often  to  be  felt  rigid 
from  atheromatous  degeneration ;  and  the  bladder  is  sometimes  irritable 
from  prostatic  enlargement.  Structural  change  may  begin  in  the  kidneys, 
and,  by  causing  a  rise  in  blood-pressure,  propel  the  blood  with  greater  force 
through  the  encephalic  arteries ;  thus  is  brought  about  an  overloaded  state 
of  the  cerebral  arteries,  and  an  increase  in  the  growth  of  the  tissues  which 
enter  into  their  structure.  The  heart's  sounds  afford  evidence  of  the  mis- 
chief which  the  arterial   tension  discloses  :    the  impulse  is  frequently  in- 


THE    HEADACHE    OF    CEREBRAL    HYPEREMIA,  35 

creased,  and  the  area  of  prsecordial  dulness  also ;  whilst  the  aortic  second 
sound  is  accentuated.  In  a  case  which  has  furnished  these  remarks,  the 
patient  was  sixty-five  years  of  age,  and  there  stole  on  gradually  a  forgetful- 
ness  of  passing  events,  and  an  indistinct  utterance,  which  finally  ended  in 
the  rupture  of  some  vessel  near  the  base  of  the  brain. 

There  is  another  form  of  active  hypersemia  due  to  structural  delicacy  in 
the  walls  of  the  bloodvessels,  and  their  feeble  resistance.  In  consequence 
of  their  thinness  they  yield  to  the  pressure  of  the  blood-current  when  the 
heart's  action  is  increased,  and  too  much  pressure  is  put  upon  them;  the 
capillaries  become  injected  and  bright,  and  the  patient  feels  the  rush  of 
blood  to  the  head.  These  patients  have  most  likely  dilated  vessels  also, 
through  paralysis  of  the  vasomotor  nerves,  and  consequently  they  all  the 
more  readily  yield  to  an  increased  pressure  of  blood.  Some  persons  suffer 
from  this  congestion  after  running  or  engaging  in  active  exertion  ;  and  it  is 
followed  by  symptoms  of  sickness  and  severe  headache.  It  is  observed  in 
many  acute  pulmonary  diseases,  and  is  the  chief  cause  of  fatal  exhaustion 
in  these  cases.  If  a  meal  has  been  recently  taken  by  a  person  whose  nerv- 
ous system  is  agitated  and  depressed,  or  if  he  exposes  himself  to  the  sun  or 
to  noise  and  confusion  after  it,  the  mental  excitement  disturbs  the  process 
of  digestion,  and  provokes  a  hyper^mic  state  of  the  cerebral  vessels.  It  is 
not  uncommon  as  a  consequence  of  aortic  insufficiency,  the  result  of  endo- 
cardial inflammation.  In  these  cases  the  carotids  are  too  full  of  blood,  and 
their  tension  and  impulse  are  strikingly  apparent.  The  undue  pressure  to 
which  the  left  ventricle  has  been  exposed  has  led  to  dilatation  and  hyper- 
trophy of  its  structure,  from  the  augmented  effort  it  is  called  upon  to  make, 
and  it  sends  onward  an  increased  volume  of  blood  through  the  diseased  and 
altered  orifice.  Now,  what  are  the  ultimate  consequences  of  mitral  valvu- 
lar derangement  on  the  cerebral  circulation  ?  Every  time  the  ventricle 
contracts  a  smaller  quantity  of  blood  is  discharged,  and  some  portions  dur- 
ing the  systole  flow  back  again,  further  crippling  the  auriculo-ventricular 
valve,  and  disabling  or  half  paralyzing  the  left  auricle.  This  induces  en- 
gorgement of  the  pulmonary  veins,  and,  indeed,  of  the  whole  venous  system, 
so  that  headache  and  dizziness  are  common,  and  death  from  congestion  or 
embolism  becomes  intelligible.  In  aortic  stenosis  the  arteries  are  scantily 
filled,  and  there  are  no  signs  of  venous  engorgement;  pallor  of  the  face, 
syncope,  and  anaemia  of  the  brain  are  the  characteristic  symptoms,  just  as 
hyperaemia  of  the  cerebral  circulation  is  associated  with  valvular  insuf- 
ficiency. 

Again,  any  condition  which  arrests  or  interferes  with  the  cutaneous  circu- 
lation will  cause  active  hyperaemia,  as  severe  exposure  to  cold,  or  the  cold 
stage  of  intermittent  fever  ;  and  then  there  is  also  paralysis  of  the  vasomotor 
nerves  accompanying  the  cerebral  bloodvessels. 

In  the  brain,  as  in  other  organs,  when  it  has  long  been  subject  to  hyper- 
aemia, there  is  developed  a  certain  amount  of  pathological  connective  tissue, 
which  gradually  contracts.  In  the  liver  and  kidney  this  pathological  pro- 
cess is  accompanied  by  reduction  in  the  bulk  of  the  organ.  The  brain 
being  in  an  unyielding  bony  case,  its  contraction  is  accompanied  by  the 
effusion  of  fluid.  This  is  a  condition  known  as  the  water-logged  brain, 
common  in  some  forms  of  insanity.  Niemeyer  has  given  it  the  name  of 
Hydrocephalus  ex  vacuo.* 

Connective  tissue  overgrowth  in  the  brain,  as  a  consequence  of  alcoholic 
indulgence,  has  been  pointed  out  by  Schroeder  Van  der  Kolk,  and  physio- 

*  Niemeyer,  Practical  Medicine,  vol.  ii,  p.  247. 


30  HEADACHES. 

logical  investigation  would  seem  to  establish  the  fact  that  the  absorption  of 
alcohol  into  the  cerebral  tissue  causes  the  nerve-cells  to  undergo  important 
physical  changes,  producing  degeneration  and  disease.* 

Passive  hypercemia  or  congestion  arises  from  any  pressure  on  the  jugular 
veins  interfering  with  the  free  return  of  the  blood  to  the  heart.  We  have 
examples  of  it  in  cases  of  glandular  enlargement  of  the  neck,  as  a  bron- 
chocele,  aneurisms  of  the  aorta,  and  hypertrophy  of  the  thyroid  ;  in  tricuspid 
insufficiency;  in  the  violent  expiratory  efforts  produced  by  straining  and 
coughing,  as  in  whooping-cough,  when  the  blood  accumulates  in  the  general 
circulation  rather  than  in  the  pulmonary.  The  brain  is  overloaded,  and 
maintained  in  this  unhealthy  condition  because  the  obstacle  cannot  be  over- 
come. This  does  not  apply  to  the  circulation  through  the  lower  organs  of 
the  body,  where  it  is  much  less  impeded.  In  all  diseases  of  the  heart,  par- 
ticularly when  the  right  ventricle  is  diseased  and  acts  imperfectly,  the  over- 
fulness  of  the  veins  leads  to  capillary  engorgement  because  the  blood  is  ob- 
structed in  them,  and  this  is  a  common  cause  of  cerebral  hypersemia.  In 
valvular  disease  of  the  right  heart  this  aifection  is  far  greater  than  when  it 
occurs  on  the  left  side,  because  the  return  of  the  blood  is  enormously  im- 
peded.f  In  cases  of  chronic  bronchitis,  with  a  weak  and  dilated  right 
heart,  this  state  is  also  of  common  occurrence.  In  pleuritic  effusion  and 
compression  of  the  thoracic  viscera,  in  emphysema  and  chronic  diseases  of 
the  lungs,  there  is  congestion  of  the  brain  from  the  overloading  of  the  sys- 
temic circulation,  when  the  right  heart  is  not  proportionately  enlarged  to 
overcome  the  impediment. 

But  I  must  not  omit  another  important  phase  of  the  gouty  diathesis,  which 
I  shall  briefly  allude  to  here,  as  it  is  rather  of  a  passive  than  of  an  active 
character.  Headache  is  the  prevailing  symptom  of  this  condition,  frontal 
and  deepseated,  and  so  continuous  that  the  nerve-structure  is  gradually 
brought  to  the  verge  of  disease.  It  may  continue  for  years,  and  end  in  apo- 
plexy or  rupture  at  last.  The  well-to-do  rector,  or  the  country  squire  who 
has  seen  sixty  summers,  is  the  victim  of  this  condition  ;  they  are  prone  to 
gouty  bronchitis  on  any  change  of  weather,  and  there  is  vesical  irritability 
with  an  abundance  of  lithic  acid  in  the  urine,  and  very  commonly  enlarge- 
ment of  the  prostate  gland.  The  digestive  functions  are  constantly  getting 
wrong,  and  there  is  a  foul  tongue,  with  much  flatulence  and  discomfort  after 
food;  the  bowels  are  habitually  costive,  and  need  aperients  to  maintain  their 
regular  action.  The  patient  cannot  exert  himself  to  his  accustomed  duty, 
and  is  too  nervous  to  seek  society.  He  has  confused  sensations  in  the  head, 
and  noises  in  the  ears ;  he  moves  along  slowly  and  carefully,  rather  than 
walks,  but  with  a  faltering  step  withal ;  and,  if  spoken  to,  or  stopped  on  his 
way,  turns  round  so  guardedly  that  his  head  seems  to  have  no  independent 
motion  from  the  rest  of  the  body.  The  heart  indicates  commencing  de- 
generative change,  and  the  aortic  valves  are  the  first  to  go  wrong.  Nearly 
all  his  disagreeable  sensations  are  referred  to  the  head;  and,  when  not 
actually  painful,  it  is  too  disordered  to  admit  of  any  exertion.  When  there 
is  no  need  for  worldly  anxiety,  he  conjures  up  ideas  of  impending  ruin,  and 
is  hysterical  or  so  nervous  that  life  is  irksome  to  himself,  and  his  presence 
unendurable  to  others.  The  blood  is  here  also  contaminated  with  nitro- 
genous waste,  and  the  cerebral  vessels  are  habitually  overloaded  from  this 
poisonous  source  of  irritation,  to  the  risk  of  threatening  rupture,  particularly 
also  if  there  is  any  deglee  of  uraemia.     The  patient's  general  demeanor  is 

*  Effects  of  Alcohol  on  the  Brain,  Lancet,  September  30th,  1876,  p.  470. 
-j-  See  Chapter  V,  on  Congestive  Headache,  where  this  subject  is  continued. 


THE  HEADACHE  OF  CEREBRAL  HYPER.EMIA.  37 

altered,  and  dejection  of  spirits  and  moroseness  of  manner  are  rather  the 
mental  traits  than  excitement  and  irritability.  Still,  there  is  general  rest- 
lessness and  a  desire  to  be  doing.  The  terrific  headache  and  the  morbid 
sensations  to  which  these  persons  are  liable  depend  on  excitement  of  the 
cerebral  cells,  scarcely  to  be  accounted  for  by  any  additional  supply  of 
arterial  blood,  but  more  to  venous  fulness  and  stagnation.  The  relation 
which  this  cell  activity  holds  to  the  blood-supply,  and  their  dependence  on 
one  another,  have  yet  to  be  determined.  With  this  headache  and  increased 
local  vascularity,  there  is  not  necessarily  associated  a  general  arterial  excite- 
ment, for  the  pulse  may  be  soft  and  quiet,  and  the  face  pallid.  These  latter 
cases  are  often  the  consequence  of  mental  anxiety  or  overstrain,  and  the 
evidences  of  exhaustion  and  low  blood-pressure  are  to  be  observed. 

When  we  reflect  on  the  anatomical  changes  in  the  vessels  and  meninges 
of  the  brain,  it  is  no  easy  question  to  decide  on  the  appearances  they  may 
be  expected  to  present  after  death.  I  am  not  aware  of  anything  constant 
in  the  amount  of  blood  in  the  cerebral  hemispheres  and  vessels,  short  of 
actual  rupture,  which  a  post-mortem  examination  reveals.  In  the  case  of 
children,  often  after  death  from  head  affections,  the  brain  is  only  mode- 
rately congested,  and  yet  the  symptoms  have  been  alarming,  and  death 
rapid,  with  insensibility  and  coma.  The  best  examples  of  congestion  and 
hypergemia  fail  to  account  for  the  symptoms  during  life.  But  when  the 
continuance  of  active  cerebral  hypersemia  has  induced  pain  in  the  head, 
disturbances  of  the  mind,  and  a  severe  degree  of  cerebral  congestion,  it  may 
result  in  delirium  and  meningitis.  This  is  by  no  means  of  rare  occurrence 
in  malarious  fevers,  which  are  so  common  in  tropical  climates.  After  death 
in  such  cases,  the  minutest  vessels  of  the  brain  have  been  found  injected, 
and  the  arachnoid  thickened  and  of  a  deep-red  color.  Extravasation  of 
blood  beneath  the  scalp  and  between  the  dura  mater  and  the  skull  is  found 
in  some  cases  of  this  sort.  The  other  internal  organs,  also,  as  the  liver, 
stomach,  and  spleen,  undergo  enlargement  and  softening  as  the  result  of 
inflammatory  action. 

SymptojTis  of  Hypercemia. — x\lthough  I  have  dwelt  at  some  length  on  the 
causes  of  congestion  and  hypercemia  of  the  brain,  it  would  be  a  deeply 
rooted  error  to  infer  that  disturbance  in  its  functions  necessarily  originates 
in  either  state,  if  actual  change  of  structure  is  excluded.  The  brain  dis- 
turbance in  fever  arises  from  the  high  temperature  and  a  change  in  the 
quality  of  the  blood,  which  is  at  variance  with  a  healthy  condition  of  the 
nerve  substance  ;  hence  delirium  and  a  comatose  state  in  low  fevers  affecting 
the  brain  are  not  infrequent,  where  the  heart's  action  is  feeble  and  the 
blood-supply  is  also  deficient. 

In  cases  of  severe  sunstroke,  where  the  patient  is  struck  down  suddenly, 
the  symptoms  are  rather  due  to  a  paralysis  of  the  functions  of  the  brain  than 
to  a  state  of  hypersemia.  The  nerve-centres  are  overheated  and  depressed, 
and,  until  the  temperature  is  lowered,  they  cannot  recover  their  action. 
These  facts  point  out  the  rational  treatment  of  the  disease.  "  As  the  hyper- 
pyrexia is  due  not  only  to  the  direct  operation  of  heat  on  the  nerve-centres 
and  tissues,  but  also  to  the  fever  set  up  by  the  disordered  vasomotor  arrange- 
ments, remedies,  such  as  may  influence  this  disturbed  condition,  have  been 
suggested.  The  results  have  appeared  in  some  cases  to  justify  the  theory  ; 
and  the  hypodermic  injections  of  morphia  and  of  quinine  have  both  been 
considered  to  produce  good  results  by  their  influence  on  the  vasomotor 
nerves,  and  their  power  in  retarding  tissue  change."  *     The  plan  of  treating 

*0n  Sunstroke,  British  Medical  Journal,  August  12th,  1876,  p.  224,  by  Sir  Joseph 
Fayrer,  K.  C.  S.  I. 


38  HEADACHES. 

sunstroke  by  the  subcutaneous  injection  of  quinine,  first  introduced  by  Sur- 
geon-Major A.  R.  Hall,  has  been  found  most  successful.  It  is  especially 
serviceable  for  troops  on  the  march  where  ice  is  unattainable  (Form.  115); 
There  is  excitement  and  cerebral  irritation  in  some  cases,  but  in  the  majority 
of  cases  the  patient  falls  down  and  gasps  for  breath,  as  in  syncope.  The 
prduction  of  heat  is  increased  by  muscular  exertion,  and  the  body  becomes 
overheated,  because  perspiration  takes  place  slowly  through  the  high  tem- 
perature of  the  atmosphere  ;  and  hence  the  overloading  of  the  vessels  of  the 
brain  and  the  other  organs  of  the  body,  but  more  particularly  congestion  of 
the  lungs,  and  distension  of  the  right  heart.  Post-mortem  examination  ver- 
ifies this  in  fatal  cases  of  sunstroke,  where  the  blood  is  fluid,  as  in  death  from 
lightning  and  blows  on  the  epigastrium.  In  mild  cases  prolonged  head- 
ache (which  is  not  an  early  symptom),  irritability,  exhaustion,  incapacity 
for  mental  exertion  and  the  concentration  of  ideas,  are  induced  by  it.  For 
it  is  important  to  remember  that  the  shock  of  the  seizure  and  the  high  tem- 
perature together  are  highly  injurious  to  the  nerve-centres,  over-loading  the 
brain  with  blood,  and  sometimes  inducing  severe  meningitis.  A  brain 
habitually  charged  with  too  much  blood  is  just  as  likely  to  lay  the  founda- 
tion of  gradual  tissue-change,  as  is  the  direct  operation  of  heat  and  exposure 
to  the  sun.  In  the  management  of  these  cases  of  hyperpyrexia  Sir  Joseph 
Fayrer  insists  on  reducing  the  temperature  as  quickly  as  possible  by  the  use 
of  the  cold  douche  to  the  head  and  body,  mustard  poultices,  and  purgative 
enemata.  He  relies  little  on  blood-letting,  and  records  that  of  numbers  of 
soldiers  who  were  struck  down  in  the  Burmese  war  in  1852  by  the  direct 
action  of  the  sun,  all  recovered  except  two,  who  were  bled  on  the  spot  where 
they  fell.  These  remarks  are  in  accordance  with  those  of  Dr.  Wilson  Fox,* 
who  says  that  cold  is  the  only  means  of  reducing  the  temperature  in  hyper- 
pyrexia. He  shows  that  venesection,  in  one  case  to  twenty  ounces,  had  no 
effect  in  checking  the  rise  of  temperature  in  acute  rheumatism ;  whilst  he 
cites  two  cases  of  recovery  under  his  own  care,  where  the  temperature  in 
one  case  reached  110°,  and  in  the  other  107.3°.  He  considers  that  vene- 
section prejudicially  interfered  with  the  cold  applications,  and  was  the  cause 
of  death  in  one  case  through  the  exhaustion  induced. 

In  simple  congestion  the  escape  of  venous  blood  is  arrested,  and  the  blood 
passes  slowly  through  the  capillaries  from  this  overfilling.  Both  in  ansemia 
and  congestive  venous  hypersemia,  the  brain  is  not  supplied  with  its  due 
amount  of  arterial  blood,  and  so  the  cerebral  symptoms  are  allied;  and  the 
general  condition  bears  a  close  resemblance  in  the  two  cases. 

The  pain  and  irritation  induced  by  active  hypereemia  are  not  precisely 
alike  in  all  instances.  At  one  time  the  functions  of  sensation  are  more 
affected  than  those  of  motion,  and  at  another  time  the  mental  faculties  are 
marked  out  for  special  implication.  The  thoughts  are  rapid,  loose,  and  un- 
connected, and  the  ideas  are  confused  and  false.  Life  is  looked  at  through 
a  false  medium.  When  the  sensory  functions  are  involved,  there  are  head- 
ache, excitability,  and  extreme  sensitiveness  to  every  impression  that  goes  on 
around,  the  slightest  sound  worrying  the  patient,  and  even  quiet  conversa- 
tion being  distasteful;  the  light  of  the  sun  causes  a  disagreeable  and  oppres- 
sive feeling  to  the  brain,  scintillations  of  light  appear  before  the  eyes,  and 
there  are  noises  in  the  ear.  Some  persons  experience  a  condition  of  hyper- 
sesthesia  periodically;  it  comes  on  suddenly,  and  lasts  a  day  or  two,  then 
goes  away  as  it  came. 

*0n  Hyperpyrexia,  1871,  pp.'  i  and  43.  These  views  are  supported  in  H.  C.  Wood's 
work  on  Thermic  Fever. 


THE    HEADACHE    OF   CEREBRAL    HYPER.EMIA.  39 

There  is  a  form  of  hyperaemia  of  the  brain  in  men  who  tax  their  intellec- 
tual efforts  to  the  highest  point,  and  who  at  the  same  time  exert  their  bodily- 
strength  by  other  duties  and  calls  on  their  attention.  They  scarcely  allow 
themselves  time  for  their  meals,  or  take  them  irregularly  or  hurriedly,  and 
perhaps  indulge  in  stimulants  to  keep  them  up  to  the  right  mark.  There  is 
headache  with  disturbed  sleep,  and  pain  at  the  back  of  the  head,  or  a  feeling 
of  blood  rushing  into  the  brain ;  sometimes  there  is  delirium.  These  per- 
sons are  nervous  and  apprehensive,  yet  they  cannot  stop  the  speed  at  which 
they  are  pushed  along  the  stream.  Sometimes  the  pulse  is  quick,  and  there 
is  fever;  or  it  is  slow  and  labored,  not  more  than  sixty  beats  a  minute,  and 
then  the  patient  is  depressed  and  more  or  less  indifferent  about  himself. 
The  urine  is  very  changeable;  at  one  time  it  is  high-colored  and  intensely 
acid,  or  it  is  as  pale  as  water,  and  contains  phosphates  in  abundance.  There 
may  be  redness  of  the  face,  but  often  there  is  pallor  and  a  worn,  exhausted 
look;  the  patient  loses  flesh  and  strength,  and  the  excitement  gives  place  to 
lethargy  and  depression.  If  he  indulges  too  freely  in  stimulants,  melancholy 
and  even  mania  may  result,  or  apoplexy  and  paralysis  may  be  the  termina- 
tion. Suddenly  the  patient  feels  bewildered  and  giddy;  he  staggers  or  even 
falls,  or  he  rushes  and  takes  wine  or  brandy  to  support  his  failing  circulation. 
His  head  is  hot;  he  cannot  engage  in  conversation,  and  is  glad  to  resign 
himself  to  rest  and  a  recumbent  posture.  After  a  few  hours'  rest  or  sleep, 
when  the  venous  blood  is  better  circulated,  and  the  supply  of  a  proper 
amount  of  arterial  blood  stimulates  the  brain  and  nervous  centres  to  healthy 
excitability,  the  patient  recovers  and  goes  on  again ;  or  if  the  condition 
continues  to  recur  from  time  to  time,  the  nervous  substance  is  structurally 
altered,  and  loss  of  consciousness  or  convulsions  are  produced. 

It  is  quite  in  accordance  with  clinical  experience  to  have  partial  hyper- 
semia  of  the  brain,  where  certain  spots  are  more  congested  than  others. 
This  may  be  due  to  tumors,  partial  softening,  and  localized  extravasation,  as 
in  lobular  pneumonia.  An  artery  may  be  compressed,  or  the  smaller  vessels 
and  the  collateral  circulation  take  on  congestive  action,  so  that  some  portions 
are  anaemic  and  others  hyperaemic  ;  and  this  is  what  we  sometimes  see  in 
other  organs  of  the  body.  Unless  there  are  local  symptoms,  the  cause  can- 
not be  found  out.  There  are  headaches  limited  and  circumscribed — con- 
traction of  one  or  both  pupils,  noises  in  the  ears,  imperfect  vision  in  one  eye, 
neuralgia  of  one  eye,  but  never  loss  of  sensibility  in  one  spot,  or  paralysis 
of  one  side.     The  treatment  consists  in  relieving  the  local  congestion.* 

In  discussing  the  question  of  hypergemia  of  organs  there  are  two  factors  to 
be  included,  the  omission  of  either  of  which  would  greatly  invalidate  any 
conclusion  that  might  be  drawn.  The  first  is  the  relation  of  the  tissues  to 
their  blood-supply.  This  is  seen  in  the  increased  blood-flow  to  an  irritated 
part,  as  a  bat's  wing,  for  instance.  The  other  is  the  effect  of  an  increased 
blood-supply  upon  the  growth  of  a  part ;  this  is  seen  in  the  elongated  limbs 
of  chronic  joint  mischief,  and  still  more  vividly  in  the  growth  of  the  cock's 
spurs,  Avhich  John  Hunter  engrafted  on  the  bird's  comb  ;  or  as  happens  in 
the  excessive  growth  of  muscle  and  bone  in  a  limb,  from  obstruction  to  the 
lymphatic  circulation.  Thus  we  find  that  there  may  be  much  vascular  hy- 
pergemia in  a  maniacal  patient,  with  but  little  general  disturbance  of  the  cir- 
culation. Here  the  cerebral  cells  attract  blood  to  themselves  in  too  great  a 
quantity.  In  other  cases  of  congestive  headache,  as  in  plethoric  persons, 
there  is  a  hypertrophied  heart,  with  throbbing  distended  carotid  arteries,  and 

*  "  Local  hypersemia,  in  fact,  is  not  exactly  local  plethora;  it  simply  implies  that  too  much 
blood  is  accumulated  in  the  vessels  of  a  part,  without  taking  any  account  of  the  nature  of 
this  blood." — Jones  <2^  Sieveking's  Pathological  Anatomy,  by  Payne,  Philadelphia,  p.  44. 


40  HEADACHES. 

an  excessive  blood-supply  to  the  brain,  which  excites  the  cerebral  cells  and 
causes  exaltation  of  the  special  senses,  producing  the  appearance  of  flashes 
of  light,  the  sound  of  ringing  bells,  and  other  ideal  sensations.  At  times 
these  conditions  are  blended,  as  in  the  vivid  sketch  of  "Preparing  for  the 
House"  in  the  diary  of  a  late  physician,  where  the  stout  country  squire, 
with  a  rubicund  face,  is  in  a  condition  of  great  excitement  at  the  prospect  of 
delivering  a  speech  which  would  defeat  his  assailants,  and  forthwith  establish 
his  reputation  as  a  politician. 

Treatment. — The  first  indications  that  call  for  fulfilment  are  to  lower  the 
vascular  system,  and  to  reduce  the  cerebral  fulness.  It  is  obvious,  however, 
that  a  separate  line  of  treatment  will  be  required  to  meet  the  special  pecu- 
liarities of  each  case.  If  the  vascular  element  predominates,  and  other  meas- 
ures fail  to  control  the  more  urgent  symptoms,  venesection  may  be  demanded 
to  save  the  patient's  life,  and  there  can  Idc  no  doubt  that  a  full  and  effective 
blood-letting  has  proved  of  great  service.  If  the  carotids  beat  violently  and 
fill  the  brain  with  blood,  then  leeching  or  cupping  ought  to  be  had  recourse 
to,  as  becomes  advisable  in  some  acute  forms  of  febrile  headache  in  young 
subjects.  In  cases  of  active  cerebral  hypereemia,  where  the  pulse  is  firm  and 
good,  aconite,  tartar  emetic,  and  other  depressants  are  to  be  selected  (Form. 
io6).  Colchicum,  in  combination  with  the  alkalies  and  iodide  of  potassium, 
will  also  be  of  service  (Form.  31-34),  if  it  appears  certain  that  the  cerebral 
vessels  are  distended,  and  the  blood-pressure  is  too  great.  The  bowels 
should  be  freely  evacuated  by  saline  purgatives  (Form.  19)  in  the  early  morn- 
ing. An  occasional  pill  containing  mercury,  with  or  without  podophyllin, 
will  rouse  the  liver  and  intestines,  and  so  bring  great  relief  to  the  head  symp- 
toms, by  tending  to  subdue  vascular  excitement  and  depress  the  circulation 
generally  (Form.  Si-94).  If  the  urine  is  scanty  and  acid,  and  aft''ords  proof 
of  lithiasis,  which  is  not  uncommon,  it  will  be  advisable  to  take  plenty  of 
diluents,  and  the  salts  of  potash  and  lithia  freely  diluted  with  water.  Fried- 
richshalle,  Pullna,  and  Hunyadi  Janos  waters  on  first  rising  in  the  morning 
act  quickly  on  the  bowels,  and  produce  no  unpleasant  effects  afterwards ; 
and  the  same  may  be  said  of  the  aerated  waters  of  Vichy  and  Carlsbad, 
which  are  favorite  remedies  with  some  persons  of  full  and  torpid  habit. 

In  place  of  a  heavy  nitrogenous  diet,  fish,  white  meats,  and  fruits  are  to 
be  preferred,  and  fermented  liquors  and  wines  should  be  forbidden. 

If  the  patient  has  strained  his  mind,  or  is  advancing  in  years,  venesection 
on  cupping  will  be  of  questionable  service,  for  the  veins  of  the  brain  and 
s«iuses  are  too  full  and  congested  to  be  relieved  by  the  attempt,  and  the 
shock  from  the  loss  of  arterial  blood  could  not  be  borne.  When,  too,  the 
circulation  is  quiet,  such  remedies  would  be  productive  of  harm  rather  than 
good  j  and  we  must  trust  to  a  darkened  room,  general  quiet,  and  remedies 
havmg  the  sedative  properties  of  hydrate  of  chloral. 

In  women  the  occurrence  of  the  menses  often  brings  relief,  if  the  patient 
is  abstemious  in  diet  and  avoids  stimulating  food.  In  those  forms  of  con- 
gestive hypersemia  from  pressure'on  the  jugular  veins,  leeches  may  be  used  to 
favor  the  escape  of  venous  blood.  When  hypersemia  results  from  overfeed- 
ing and  stimulants,  lessening  the  diet,  moderation  in  living,  and  walking 
exercise  will  be  necessary ;  but  no  two  cases  are  alike,  and  some  modifica- 
tion will  be  required. 

In  treatment  it  is  of  the  highest  importance  to  discriminate  the  two  fac- 
tors previously  mentioned;  the  first  is  the  relation  of  the  tissues  to  their 
blood-supply,  and  the  second  is  the  effect  of  an  increased  blood-supply  upon 
the  growth  of  a  part.  The  proportion  of  each  factor  in  every  individual 
case  must  be  carefully  weighed,  for  in  one  the  circulation  needs  depressing, 


THE  HEADACHE  OF  CEREBRAL  HYPER.EMIA.  4 1 

and  in  the  other  sedatives  and  rest  are  the  chief  indications.  In  one  the  line 
of  treatment  is  to  reduce  the  excessive  blood-supply,  which  keeps  up  too 
much  excitement  in  the  brain ;  in  the  other  the  excited  brain-cells  are  at- 
tracting blood  too  freely,  and  the  course  to  be  adopted  is  to  lessen  activity 
and  their  demand  for  blood.  For  this  condition  bromide  of  potassium,  hy- 
drate of  chloral,  and  opium,  are  the  chief  remedies  to  rely  upon. 

With  regard  to  the  action  of  sedative  remedies  in  hyperaemia  of  the  brain, 
bromide  of  potassium  is  one  of  the  most  remedial  and  curative  agents  we 
possess  in  the  treatment  of  nervous  disorders.  It  has  been  clearly  shown  by 
scientific  observers  that  it  is  a  most  efficacious  remedy  in  hypersemic  forms 
of  headache,  and  also  in  those  varieties  of  nervous  headache  where  the  cere- 
bral cells  are  excited,  and  the  emotional  framework  is  highly  strung.  As 
J  bromide  of  potassium  controls  sexual  excitement,  it  may  be  expected  to  sub- 
^  due  cerebral  excitement  also,  and  dissipate  those  conflicting  thoughts  and 
passions  which  stir  us  to  anger,  and  aggravate  the  trifling  incidents  of  daily 
life.  Our  chief  experience  has  been  derived  from  its  efficacy  in  the  treat- 
ment of  epilepsy.  As  a  calmative  and  narcotic,  and  as  a  remedy  controlling 
vascular  excitement,  it  is  usually  admitted  to  occupy  the  first  rank.  By 
reducing  the  irritability  and  lessening  the  fits,  it  controls  the  congestion  on 
which  the  headache  depends.  Clouston  (Fothergillian  Prize  Essay)  found 
half-drachm  doses  of  the  bromide  of  potassium,  of  tincture  of  cannabis 
indica,  and  of  tincture  of  hyoscyamus,  very  useful  in  the  sleeplessness  of  talk- 
ative mania  (Form.  63).  I  have  often  given  the  bromide  and  the  cannabis 
-  indica  together  with  great  advange  in  smaller  doses  (Form.  64),  and  I  have 
known  full  doses  of  henbane  with  camphor,  either  in  the  shape  of  pill  or 
mixture,  prove  an  excellent  and  reliable  sedative  (Form.  65-93).  ^^  the 
persistent  headache  which  follows  sunstroke,  bromide  of  potassmm  is  the 
most  serviceable  remedy.*  Hydrate  of  chloral  is  sometimes  given  with  ad- 
vantage, either  alone  or  in  combination  with  the  bromide  (Form.  66-67). 
When  chloral  is  given  alone  it  acts  by  depressing  the  heart's  action  and  less- 
ening blood-pressure,  on  which  the  cerebral  excitement  depends.  Men 
advanced  in  life,  who  have  still  active  duties  to  perform  which  require 
mental  exertion,  find  their  headaches  relieved  by  a  full  dose  of  chloral  on 
retiring  to  bed.  This  indicates  the  hypersemia  of  vasomotor  paresis.  The 
sleep  is  sometimes  broken  and  disturbed  in  these  subjects,  and  there  is  throb- 
bing and  a  disagreeable  sensation  about  the  temples;  but  the  next  night,  and 
for  many  succeeding  nights,  the  sleep  is  calm  and  peaceful,  and  the  patient 
goes  about  his  work  with  renewed  pleasure.  This  very  action  makes  the  drug 
a  seductive  one,  and  it  should  never  be  taken  except  under  medical  super- 
vision. It  probably  has  a  greater  effect  upon  the  vascular  system  than  the 
bromide,  which  would  seem  chiefly  to  have  its  action  confined  to  the  nerve- 
^  centres.  Bromide  of  potassium  with  digitalis  is  serviceable  if  the  pulse  is  fast 
-  and  feeble  and  the  patient  has  a  weak  heart,  or  has  overdone  himself  in  any  way. 
Ergot  is  a  remedy  highly  spoken  of  by  some  authorities,  but  I  have  not 
employed  it,  with  so  many  more_rem.edies  at  hand.  "  I  have  found  it  almost 
uniformly  efficacious  in  reducing  excitement,  in  shortening  attacks,  in  wid- 
ening the  intervals  between  them,  occasionally  in  altogether  preventing  the 
recurrence,  and  in  averting  that  perilous  exhaustion  by  which  excitement  is 
so  often  succeeded."  Drs.  Bucknill  and  Tuke  add,  "  Dr.  Browne  explains 
its  beneficial  action  by  its  influence  in  contracting  the  vessels  of  the  brain, 
and  administers  the  liquid  extract  of  ergot  in  doses  of  from  3ss.  to^j  three 

*  Dr.  Morehead,  On  Sunstroke,  in  A  System  of  Medicine,  edited  by  J.  Russell  Reynolds, 
M.  D.,  F.  R.  S.,  vol,  ii.,  p.  142. 

3 


42  HEADACHES. 

times  a  day,  or  S]  to  3ij  of  the  pharmacopoeial  tincture."*     I  do  not  like 
these  large  doses,  for  the  reasons  given  in  another  place. f 

One  of  the  most  powerful  agents  we  possess  in  the  treatment  of  hypersemic 
conditions  is  cold.  Cold  applied  to  the  head  is  admitted  to  act  in  one  of 
three  ways  : 

1.  By  exerting  a  direct  action  on  the  superficial  vessels  of  the  scalp,  and 
the  parts  within  the  cranium. 

2.  By  diminishing  the  blood-supply,  and  contracting  the  vessels. 

3.  By  exerting  a  sedative  action  on  the  nervous  centres. 

Some  estimate  of  its  power  on  the  capillary  circulation  may  be  imagined 
from  the  effect  of  immersion  in  a  cold  bath  for  a  few  minutes,  where  the 
temperature,  as  in  hj'perpyrexia,  may  be  reduced  several  degrees  in  an  in- 
credibly short  space  of  time.  M.  Marey  has  shown  by  a  sphygmographic 
tracing,  that  after  exposure  to  a  cold  bath  of  one  minute,  there  is  consider- 
able tension  and  hardness  in  the  pulse  in  consequence  of  contraction  in  the 
cutaneous  capillaries,  and  an  obstacle  to  the  passage  of  blood  from  the  ar- 
teries. The  effect  of  a  hot-air  bath,  as  we  all  know,  is  to  relax  the  arterial 
system,  and  to  produce  dilated  vessels  and  general  enlargement  of  the  capil- 
lary circulation. 

The  pulse  is  soft  and  full,  and  the  increased  frequency  with  which  the 
heart  acts  diminishes  its  force  and  power,  enabling  the  blood  to  pass  freely 
into  the  veins. 

When  cold  is  applied  to  the  head,  one  m.ode  of  action  is  considered  to  be 
by  abstracting  heat  from  the  scalp.  There  may  not  be  a  general  agreement 
on  the  subject,  but  it  seems  borne  out  by  practical  conclusions.  Cold  is  so 
powerful  an  agent  that  long  exposure  to  it  has  resulted  in  the  death  of  the 
part  to  which  it  is  applied  ;  and  congestion  of  the  internal  organs,  as  the 
brain  and  lungs,  has  been  found  after  death,  preceded  by  a  tendency  to 
sleep  and  apoplectic  coma.  Here  it  is  highly  probable  that  a  brief  applica- 
tion of  cold  may  assist  in  the  removal  of  the  venous  stasis,  which  a  more 
prolonged  application  tends  to  induce;  and  there  is  nothing  adverse  to  the 
physiological  conclusion  that  cold,  by  contracting  the  vessels,  may,  by  a  seda- 
tive action  on  the  nerve-centres,  diminish  the  flov/  of  blood  generally;  and 
it  would  appear  to  have  this  effect,  as  it  will  lower  the  pulse,  and  in  control- 
ling the  action  of  the  heart  lessen  the  arterial  supply  to  the  brain.  From  a 
series  of  carefully  conducted  experiments  performed  by  Dr.  Benham  on  the 
dead  subject,  he  ascertained  "that  as  long  as  a  fluid  of  a  certain  tempera- 
ture is  passing  through  the  vessels  of  the  intracranial  tissues,  the  application 
of  even  the  most  intense  cold  to  the  outside  of  the  scalp  has  no  effect  in 
lowering  their  temperature. "|  Now  this  is  what  might  be  expected  when 
we  consider  the  deep  tissues  through  which  the  cold  has  to  act.  It  may  be 
capable  of  abstracting  a  certain  amount  of  heat  from  the  scalp  and  superficial 
tissues,  but  can  it  exert  any  physiological  effect  on  the  tissues,  within  the 
rigid  osseous  skull?  It  seems  unlikely  that  it  can  do  so  without  causing  con- 
gestion, or  even  inflammation ;  yet,  moderately  applied,  it  may,  through  the 
influence  of  the  nervous  system,  control  the  temperature  to  some  extent. 
Even  in  experiments  performed  on  living  dogs  under  the  influence  of  chlor- 
oform, although  the  temperature  was  temporarily  lowered  2°,  it  did  not  con- 
tinue to  fall,  but  soon  rose  to  the  normal  standard.      This,   therefore,   was 

*  Psychological  Medicine,  1874,  p.  745. 
■j-  See  Chapter  XIV.,  on  Headaches  of  Advanced  Life. 

J  On  the  Therapeutic  Value  of  Cold  to  the  Head,  West  Riding  Lunatic  Asylum '  Medical 
Reports,  vol.  iv.,p.  157. 


THE    HEADACHE    OF    CEREBRAL    HYPER^.MIA. 


43 


rather  due  to  some  effect  on  the  vessels  through  the  nervous  system  and 
sensory  nerves,  than  to  any  effect  on  the  blood  temperature. 

Mr.  Knowsley  Thornton*  (to  whom  I  am  indebted  for  the  engraving 
here  given),  about  four  years  ago,  introduced  into  the  Samaritan  Hospital  an 
ice  cap  for  the  head,  to  be  used  as  the  easiest  and  best  means  of  reducing  the 
high  temperature  and  pyrexia  which  sometimes  succeed  ovariotomy.  It  has 
received  the  sanction  of  Mr.  Spencer  Wells,  and  now  forms  one  of  his  re- 
liable remedies  in  the  after-treatment  of  these  cases.  The  apparatus  is  not 
expensive,  and  is  easy  of  application.  It  consists  of  india-rubber  tubing 
about  the  thickness  of  the  little  finger.  This  is  coiled  round  so  as  to  form  a 
closely-fitting  cap  for  the  head,  communicating  on  one  side,  by  means  of  the 
tubing,  with  a  pail  of  iced  water,  elevated  about  two  feet,  and  placed  on 
one  side  of  the  patient's  bed,  and  communicating  on  the  other  side  Avith  a 
pail  to  receive  the  water  which  has  passed  through  the  cap.     The  two  pieces 

of  tubing,  in  fact, — the 
one  conveying  water  to 
the  cap,  and  the  other  al- 
lowing its  escape  from  it, 
— are  the  two  strings  of  a 
cap,  so  to  speak. 

The  benefit  of  the  ice 
cap  seems  to  me  incalcu- 
lable in  cases  of  great  vas- 
cular fulness,  for  like  cold 
affusion  it  exerts  a  seda- 
tive effect  upon  the  heart, 
and  rather  encourages  the 
free  action  of  the  skin, 
which  is  one  of  the  chief 
means  of  lessening  arter- 
ial tension. 

When  the  patient  is 
flushed  and  excited,  and  there  are  headache  and  confusion  of  the  mind,  im- 
mediate relief  follows  the  application  of  the  ice  cap  in  a  large  proportion 
of  cases;  the  high  sthenic  action  is  reduced,  and  the  face  loses  its  florid 
appearance  and  becomes  peaceful  and  calm.  If  bronchial  irritation  and 
cough  are  threatening,  they  rapidly  subside,  and  the  excited  action  of  the 
heart  gives  way  to  a  more  steady  and  regular  movement,  whilst  the  pulse  is 
also  reduced  in  force  and  frequency.  If  the  temperature  has  been  steadily 
rising,  it  usually  begins  to  fall  perceptibly,  and  if  not  at  once  it  does  so  in 
the  course  of  an  hour  or  two,  unless  the  elevation  is  due  to  septic  causes  : 
and  even  in  nearly  all  cases  the  ice  cap  may  be  said  to  check  the  rapidity 
of  the  rise,  at  whatever  stage  of  the  pyrexia  it  is  applied.  When  the  cere- 
bral symptoms  are  relieved,  and  the  ice  cap  is  hastily  discontinued,  the 
head  frequently  becomes  again  hot  and  uncomfortable,  until  it  is  reapplied. 
Patients  are  in  the  habit  of  begging  for  it  during  their  recovery,  whenever 
they  have  once  used  it ;  and  in  many  other  cases  of  cerebral  hypersemia 
which  have  been  caused  by  alcoholic  indulgence,  and  other  causes  of  ner- 
vous exhaustion,  with  high  temperature  and  febrile  disturbance,  it  is  useful. 
The  headache  of  active  cerebral  congestion,  and  the  nervo-hyperaemic  head- 
ache in  the  acute  and  early  stages,  yield  more  quickly  to  the  ice  cap  than  to 
all  the  drugs  in  the  pharmacopoeia;  and  when  this  is  not  obtainable.  Dr. 
Chapman's  spinal  ice  bag  is  an  excellent  substitute. 

*  Improved  Ice  Water  Cap  for  applying  Cold  to  the  Head  in  Hyperpyrexia,  by  J.  Knows- 
ley Thornton,  M.  B.,  M.  C,  in  Medical  Times  and  Gazette,  May  27,  1876. 


CHAPTER  III. 


.=*?^^^ 


SYMPATHETIC    HEADACHE. 

Extreme  Frequency  of  this  Variety  of  Headache,  particularly  in  Women  who  suffer  from 
Menorrhagia  and  Uterine  and  Ovarian  Irritation — Sympathetic  Ganglia  of  the  Uterus — Its 
abundant  Nerve-supply — Effects  on  the  Cerebral  Vessels  of  Section  and  Galvanization  of 
the  Cervical  Sympathetic — Researches  of  Dr.  Brown-Sequard  and  Professor  Bernard — 
Examples  of  Headache  attributable  to  Ovarian  Irritation — Typical  Specimen  of  Sympa- 
thetic Headache  from  taking  Ice  into  the  Stomach,  mentioned  by  Dr.  Symonds. 

Occipital  Headache — Causes  of  Pain  in  this  Locality  frequently  due  to  an  Affection  of  the 
Occipital  Nerves — Its  Significance  vi'hen  of  Long  Standing — Mr.  Hilton's  Opinion  of  Pain 
at  the  Back  of  the  Head  as  a  Diagnostic  Sign. 

In  well-marked  examples  of  this  headache,  irritation  proceeds  at  a  distance 
from  the  sensorium,  as  in  the  case  of  decayed 
teeth,  faulty  or  arrested  digestion,  and  ovarian 
excitement.  The  headache  is  dependent  on  these 
eccentric  sources  of  irritation,  and  the  most  per- 
fect examples  of  it  happen  only  when  the  ner- 
vous system  is  already  delicate  or  impaired. 

Abundant  instances  might  be  adduced  to  prove 
how  impressions  are  conducted  along  the  pneu- 
mogastric  nerve  and  the  great  sympathetic. 
There  is,  so  to  speak,  a  sort  of  influence  travel- 
ling through  many  channels,  and  these  two  es- 
pecially, till  it  reaches  the  brain,  where  it  changes 
the  conditions  of  repose  into  heightened  sensi- 
bility and  morbid  exaltation.  This  influence, 
when  once  excited,  produces  modifications  in 
the  brain,  by  weakening  its  inherent  strength. 
The  nature  of  these  changes,  and  the  relations 
that  exist  between  organs  so  remote  and  distinct, 
must  be  recognized  before  we  can  ascertain  their 
mutual  relation,  and  how  an  antagonism  in  their 
functions  is  produced. 

A  nervous  headache  is  as  often  sympathetic 
as  it  it  is  idiopathic;  that  is,  it  is  as  much  the 
sequel  of  faulty  action  in  a  distant  organ  as  it  is 
in  the  brain  itself.  Sympathetic  headache  is  of 
frequent  occurence  in  women  of  excitable  tem- 
perament, and  is  periodically  excited  in  them 
when  the  uterine  loss  is  natural,  or  scanty,  or 
excessive ;  and  hence  we  must  seek  for  an  expla- 
nation in  the  cerebral  functions  themselves. 
Women  are  often  to  be  met  with  who  suffer  from 


DIAGRAM  SHOWING  THE  COURSE  OF 
THE  VASOMOTOR  NERVES  OF  THE 
LIVER,  ACCORDING  TO  CYON  AND 
ALADOFF. 

These  nerves  are  indicated  by  the 
dotted  line  which  accompanies  them. 
a.  Vasomotor  centre ;  b.  Trunk  of 
vagus  ;  c.  Passage  of  the  hepatic  vas- 

it  at  these  times:  and  then  the  headache  and   omotor  nerves  froni  the  cord  along  the 

■'    .  vertebral  artery;  a.  Fibres  going  on 

sickness     are    both     intense.         Ihe     sympathy    be-     each  side   of  the  subclavian   artery, 

tween  the  stomach  and  encephalon  is  so  great, 
that 


and  forming  the  annulus  of  Vieussens; 

First   dorsal   ganglion ;  _/".   Gangh- 

a    little    rich    food,   or    noise,   or    a    shock,   or     ated  cord  of  the  sympathetic ;  ^.  The 

.     .  .  1       .  .  1  1  •         .  •  r  spinal   cord ;    h.   Splanchnic    nerves ; 

fatigue,  or  exertion  during  the  digestion  of  a  z.  coeHac  ganglion,  from  which  vaso- 
meal,  will  invite  an  attack.  These  people  are  C:°e's°ina^resLr;'°^.'VeTung',^"to 
naturally  nervous,  and  in  many  instances  it  will   which  fibres  of  the  vagus  are  seen  to 

,        ^  J  •  •         ii,    4.  4-1        „ 4.        „  be  distributed ;  /.  The  liver ;  ?«.   The 

be  found  on  inquiry  that  the  parents  on  one  or   i„ustine-  «  The  arch  of  the  aorta. 

C44) 


SYMPATHETIC    HEADACHE.  45 

both  sides  of  the  family  have  equally  suffered ;  or  insanity  or  nervous  disease 
has  carried  off  some  members  of  it.  They  have  perhaps  led  an  anxious  life 
from  an  early  period  of  their  career,  and  have  taxed  the  intellect  inordi- 
nately, when  the  growth  of  bone  and  muscle  were  most  actively  proceeding. 

The  patient  who  is  eminently  nervous  asserts  that  her  complaint  is  bilious; 
and  although  in  such  a  case  as  that  just  referred  to,  sickness  begins  immedi- 
ately with  the  pain,  it  proves  no  more  than  this,  that  the  extreme  suscepti- 
bility of  the  cranial  nerves  responded  to  the  impression  made  upon  the 
gastric  nerves  by  the  food  that  was  taken.  Not,  however,  that  the  act  of 
digestion  is  necessary  to  originate  the  pain ;  for  too  long  fasting  or  a  continued 
train  of  unhappy  thoughts  will  invite  it.  In  a  patient,  aged  thirty-nine,  who 
consults  me  from  time  to  time,  the  pain  begins  as  frequently  in  the  left 
temple  as  in  the  right,  and  as  often  in  the  occiput  as  in  either  of  these  places. 
This  sympathetic  headache  comes  on  sim.ultaneously  with  the  catamenia, 
although  the  function  is  regular.  It  is  excited  by  ovarian  irritation,  and 
differs  in  no  respect  from  the  nervous  form  except  that  there  is  a  greater 
chance  of  cure  in  these  cases  than  in  those  we  may  designate  as  idiopathic ; 
as  with  the  cessation  of  the  catamenia  some  physiological  change  may  take 
place  in  the  constitution  which  modifies  the  whole  functions  of  life,  and  the 
head  is  no  longer  excited  to  morbid  action.  ' 

Within  the  muscular  walls  of  the  uterus  are  imbbedded  numerous  sympa- 
thetic ganglia,  acting  as  originators  of  evil,  alone  or  in  concert  with  the 
cerebro-spinal  system.  When;  from  the  periodic  nature  of  the  menstrual 
functions,  more  blood  is  determined  to  the  uterus  than  in  the  intervals  when 
vascular  energy  is  less  marked,  there  is  at  the  same  time  a  greater  evolution 
of  nerve-force,  which  involves  it  in  irritation,  and  from  thence  the  irritation 
is  conveyed  to  the  sympathetic  filaments  which  accompany  the  bloodvessels 
of  the  brain.  When  these  headaches  are  threatening,  the  sympathetic  nerve 
is  engaged  in  regulating  the  supply  of  blood  to  the  uterus,  and  its  influence 
is  exerted  in  increasing  or  lessening  the  amount  of  secretion.  The  patient, 
too,  feels  cold  and  shivering,  as  is  the  case  during  the  cold  stage  of  inter- 
mittents,  and  there  is  a  diminished  supply  of  blood  to  the  surface;  the 
secretions  are  scanty,  the  pulse  feeble,  and  the  extremities  are  cold.  These 
are  striking  manifestations  of  those  conditions  of  headache  over  which  the 
sympathetic  system  presides,  uniting  distant  organs  in  their  sympathies, 
acting  as  the  conductors  of  impressions,  and  giving  rise  to  the  sensation  of 
pain,  either  alone  or  through  the  medium  of  the  cerebro-spinal  nerve-fibres, 
which  are  closely  united  together  in  all  parts  of  the  body. 

The  lectures  delivered  by  Dr.  E.  Brown-Sequard*  a  few  years  ago  throw 
much  light  on  this  interesting  subject.  Professor  Bernard  found,  from  ex- 
periments he  performed  in  1851,  that,  when  the  cervical  sympathetic  nerve 
was  divided,  a  considerable  afflux  of  blood  in  the  head  took  place  in  those 
parts  beyond  the  point  of  section  of  the  sympathetic. 

Dr.  Brown-Sequard  (who  afterwards  repeated  the  same  experiments  with 
like  results)  attributed  this  to  the  influence  of  the  nerves  on  the  walls  of  the 
bloodvessels,  the  latter  becoming  paralyzed  after  section  of  the  sympathetic. 
He  moreover  found,  as  he  anticipated,  by  another  experiment,  that  galvani- 
zation of  the  nerve  led  to  the  opposite  effect,  the  bloodvessels  contracting 
and  the  temperature  and  the  blood  in  the  vessels  diminishing.  Apart  from 
any  knowledge  of  Brown-Sequard's  discovery.  Professor  Bernard  soon  after- 
wards announced  that  he  had  seen  galvanization  of  the  sympathetic  nerve 

*0n  the  Physiology  and  Pathology  of  the  Central  Nervous  System,  Lancet,  Lecture  IX., 
vol.  ii,  p.  441,  October  30th,  1858. 


46  HEADACHES. 

have  precisely  the  same  effect ;  and  this  was  corroborated  by  the  researches 
of  some  British  physiologists ;  so  that  it  came  to  be  acknowledged  by  differ- 
ent investigators  that,  whilst  galvanization  of  the  sympathetic  led  to  the 
contraction  of  the  bloodvessels,  section  of  the  same  nerve  produced  the  re- 
verse effects. 

Dr.  Brown-Sequard  smxis  up  the  phenomena  briefly  under  the  following 
heads : 

Section  of  the  Nerves. 

1.  Dilatation  of  bloodvessels. 

2.  Afflux  of  blood. 


Increase  of  vital  properties. 


Galvanization  of  the  Nerve. 

1.  Contraction  of  bloodvessels. 

2.  Diminution  of  blood. 

3.  Decrease  of  vital  properties. 


Dilatation  of  the  bloodvessels,  after  section  of  the  nerve,  necessarily  in- 
creases the  quantity  of  blood  passing  through  these  vessels  in  a  given  time, 
and  produces  an  excessive  amount  of  cerebral  congestion.  "The  hanging 
down  of  an  animal,  by  holding  it  by  its  hind-legs,  in  producing  a  conges- 
tion in  the  head,  produces  very  nearly  all  the  effects  of  this  section."* 

From  these  experiments  it  is  apparent  that  the  action  of  the  sympathetic 
nerve  exerts  an  extraordinary  regulating  effect  on  the  condition  of  the 
bloodvessels  of  the  brain,  and  through  them  regenerates  or  impairs  the 
properties  of  the  nervous  matter. 

"However,  we  are  ready  to  acknowledge  that  there  are  other  causes  of 
active  circulation  in  the  head,  after  the  section  of  the  cervical  sympathetic, 
besides  the  paral3'sis  of  the  bloodvessels.  The  very  fact  that  there  is  more 
blood,  producing  an  increase  in  nutrition  and  secretion — a  fact  which  de- 
pends chiefly,  as  we  have  said,  upon  the  paralysis  of  bloodvessels — produces 
an  increase  in  the  normal  suction  power  of  the  capillaries.  In  other  words, 
the  greater  afflux  of  arterial  blood  is  itself,  through  the  increased  chemical 
changes  of  nutrition  and  secretion,  a  cause  of  .attraction  of  arterial  blood. 
To  this  cause  another  one  of  the  same  kind  ought  to  be  added :  it  is,  that  as 
there  is  more  blood  the  temperature  is  increased,  and  as  the  temperature  is 
augmented  the  chemical  changes,  v/hich  are  a  cause  of  attraction  of  blood, 
are  also  augmented.  From  this  statement  it  may  be  concluded  that  the 
primitive,  and,  I  may  say,  by  far  the  principal,  cause  of  augmentation  in 
the  afflux  of  blood  is  the  absence  of  contraction  of  the  bloodvessels,  which 
allows  this  liquid  to  pass  easier  there  than  elsewhere. "f 

In  any  other  persons  who  suffer  from  a  sympathetic  nervous  headache,  the 
pain  is  of  a  continual  shooting  character,  as  though  a  nail  was  being  driven 
into  the  head.  It  is  neuralgic,  following  the  course  of  a  particular  nerve  or 
branch  till  it  locates  itself  in  the  centre  of  the  nervous  system.  It  is  more 
severe  in  the  morning  and  evening  than  during  the  rest  of  the  day,  and  the 
sight  is  confused  and  dim.  The  pain  may  commence  over  one  ear,  shoot 
up  to  the  top  of  the  head,  and  then  extend  backwards  to  the  occiput.  The 
pain  is  sometimes  of  a  smarting  character,  and  is  attended  with  a  sinking  sen- 
sation in  the  stomach.  Any  stimulant,  as  a  little  beer  or  wine  in  the  middle 
of  the  day,  will  bring  it  on.  Although  worry,  hard  work,  and  continual  anx- 
iety invite  these  headaches,  the  patient  is  not  necessarily  fidgety  or  irritable, 
and  the  attacks  are  unattended  with  sickness.  A  patient,  who  suffered  in  the 
way  I  have  described,  said:  "I  have  two  sons  at  sea,  and  if  I  could  get 
over  the  idea  that  I  should  not  see  them  again,  I  am  sure  I  should  not  suffer 
so   frequently."     When  with  this  anxiety  of  mind  the  catamenia  are  too 

*  Sur  les  Effets  de  la  Section  et  de  la  Galvanisation  du  Grand  Sympathique,  Paris,  1854. 
t  On  the  Physiology  and  Pathology  of  the  Central  Nervous  System,  Lancet,  Lecture  IX, 
vol.  ii,  p.  442,  October  30th,  1858. 


SYMPATHETIC    HEADACHE,  47 

active,  we  have  the  best  instance  of  sympathetic  nervous  headache.  The 
patient,  being  sleepless  and  unable  to  obtain  rest,  will  pace  the  room  all 
night,  and  tell  you  that  her  senses  are  departing. 

Anomalous  sensations  in  the  head,  of  various  kinds,  are  complained  of  by 
some  persons. 

An  unmarried  woman,  thirty-three  years  of  age,  who  was  under  my  care 
in  June,  1876,  with  a  sympathetic  nervous  headache,  felt  on  lying  down  a 
noise  in  her  head  like  the  ticking  of  a  watch,  which  she  never  experienced 
at  any  other  time.  It  sometimes  seized  one  temple,  and  then  the  other  ; 
sometimes  it  fixed  itself  in  the  forehead,  and  sometimes  it  was  seated  over 
one  ear  (clavus)  ;  there  was  also  the  sensation  of  a  heavy  weight  at  the  back 
of  her  eyes,  but  there  was  no  actual  pain.  The  patient  had  been  subject  to 
bilious  headaches  since  she  was  a  child,  and  the  attacks,  until  a  few  years 
ago,  always  ended  in  the  bringing  up  of  bile.  Formerly,  the  headaches 
came  on  at  every  catamenial  period,  and  now  they  do  not  happen  oftener 
than  once  in  three  months.  The  tongue  is  furred,  and  there  is  some  flatu- 
lence after  meals ;  but  there  is  no  uterine  ulceration  or  leucorrhoeal  dis- 
charge worth  mentioning.  Nothing  is  clearer  than  that  this  case  owed  its 
origin  to  ovarian  irritation  ;  but  it  is  inexplicable  why  the  pain  should  now 
recur  only  once  in  three  months,  instead  of  at  each  catamenial  period.  The 
patient  derived  great  relief  from  the  bromides  of  potassium  and  ammonium, 
and  for  a  time  lost  the  ticking  sensation  altogether  ;  but  when  she  was  over- 
fatigued,  immediately  she  laid  her  head  on  the  pillow  there  was  a  buzzing 
sensation  in  the  ears,  and  if  she  looked  upwards  she  was  giddy.  When  there 
was  pain  at  the  back  of  the  head  there  was  always  giddiness,  and  a  queer 
sensation  which  she  was  unable  to  define. 

Here  is  another  case  in  which  ovarian  irritation  and  uterine  loss  have  pro- 
duced a  sympathetic  headache,  and  I  give  it  as  an  illustration  of  a  group  of 
cases  which  are  of  common  occurrence.  The  patient,  E.  S.,  thirty-one 
years  of  age,  thin  and  pallid,  who  has  had  one  child,  suffers  from  an  excess 
of  catamenial  loss.  Her  headache  has  now  been  continuous  and  severe  for 
six  weeks,  but  she  has  suffered  more  or  less  since  she  was  fourteen,  and  dates 
the  commencement  of  it  from  the  time  when  the  catamenia  first  appeared. 
This  has  always  been  frequent  and  excessive  in  quantity,  and  she  is  scarcely 
free  from  a  headache,  when  the  return  of  the  catamenia  brings  it  on  again. 
Between  the  periods  there  is  a  great  deal  of  leucorrhoea  and  pain  in  the 
back.  The  pain  begins  with  the  period,  in  the  pit  of  the  stomach  (solar 
plexus),  with  the  sensation  of  a  heavy  and  oppressive  weight,  which  is  speed- 
ily followed  by  headache  (generally  in  the  left  temple  and  side  of  the  head), 
as  though  something  was  being  driven  into  it.  If  it  lasts  long  the  pain 
extends  over  the  whole  head,  particularly  the  occiput,  which  she  constantly 
throws  back  against  the  spine,  or  on  one  side,  to  obtain  ease.  When  the 
pain  is  severe,  she  is  always  sick  and  deaf,  and  there  are  noises  in  the  ears 
like  the  roar  of  the  sea  or  the  sound  of  a  distant  howling  wind.  At  the 
time  of  these  headaches  the  bowels  are  obstinately  costive,  and  she  cannot 
get  relief  until  they  have  acted;  the  pulse  is  weak,  and  the  hands  and  feet 
are  cold.  When  the  pain  is  coming  on,  the  pupils  are  contracted  and  sensi- 
bility is  increased,  the  head  is  hot  and  flushed,  and  the  bowels  are  not  free. 
When  they  are,  and  no  food  has  been  swallowed  for  some  time,  her  face  is 
as  pallid  as  marble. 

It  can  scarcely  be  contended  that  these  cases  were  not  due  to  uterine  and 
ovarian  irritation.  In  one  case  we  have  seen  that  no  headache  was  com- 
plained of  till  the  menstrual  period  was  established,  and  from  that  time  it 
recurred  periodically.     In  the  last  case  to  which  I  have  referred,  the  patient 


48  HEADACHES. 

had  filled  a  hard  and  worrying  situation  for  years,  and  the  catamenial  losses 
were  always  considerable;  so  that  the  continuance  of  two  depressing  causes 
fully  accounted  for  the  general  tone  of  the  nervous  system  being  lowered, 
and  for  a  predisposition  to  headache. 

But  it  is  doubtful  whether  any  excitement  or  disturbance  of  the  uterine 
functions  would  solely  produce  these  headaches  unless  the  nerves  of  the  brain 
were  morbidly  irritable;  for  I  have  known  the  general  health  greatly  reduced 
by  losses  of  blood,  and  menorrhagia  persist  till  the  quality  of  the  discharge 
became  almost  colorless,  and  the  patient  blanched,  without  any  headache 
supervening. 

Many  diseases  have  a  tendency  to  spread  and  extend  from  one  part  to 
another.  Whether  the  duodenum  or  any  other  portion  of  the  intestinal  tract 
is  the  seat  of  offensive  and  irritating  secretions,  or  whether  the  uterus  and 
ovaries  are  morbidly  sensitive,  the  local  disturbance  is  exceedingly  prone  to 
increase,  and  involve  contiguous  and  even  remote  organs  in  derangements. 
Irritation  arising  from  these  and  similar  sources,  travels  by  the  sympathetic 
to  the  brain. 

In  cases  of  true  sympathetic  headache  the  susceptibility  to  pain  is  far 
greater  from  some  causes  than  it  is  from  others,  according  to  the  state  of  the 
patient's  health  at  the  time  the  attack  is  provoked.  If  a  person  subject  to 
headache  sits  down  exhausted  to  his  dinner,  he  will  probably  pay  the  penalty 
of  an  attack  for  taking  into  his  stomach  a  meal  when  the  gastric  nerves  are 
oversensitive,  and  the  secretion  from  its  walls,  instead  of  being  clear  and 
acid,  is  tenacious  and  alkaline.  But  in  another  person  such  remote  irritation 
may  not  have  this  effect;  Avhilst  exposure  to  cold  or  the  strong  light  of  a 
theatre  would  bring  on  an  attack  at  once. 

"A  typical  specimen  of  sympathetic  headache  is  presented  in  that  form, 
more  than  once  adverted  to,  which  supervenes  on  taking  ice  into  the  stom- 
ach. Within  an  hour  or  two,  sometimes  sooner,  pain  will  come  on  in  the 
supraorbital  ridge  of  the  temple,  attack  the  eye,  dip  down  into  the  upper 
jaw,  or  extend  itself  over  one  lateral  half  of  the  head,  acquiring  the  violence 
of  a  tic  douloureux.  The  origin  of  this  pain  proves  unquestionably  how  an 
impression  may  be  made  on  the  nerves  of  a  distant  organ,  which,  without  pro- 
ducing any  immediate  inconvenience  in  that  part,  is  conveyed  to  distant 
organs,  and  lights  upon  some  particular  set  of  nerves  ready  to  take  offence 
from  such  a  cause,  but  which  have  shown  their  sensibility  to  disturbing 
causes  in  no  other  manner. ' '  * 

Occipital  Headache. — It  is  a  question  of  the  gravest  importance  in  ascer- 
taining the  cause  of  headache  to  trace  the  connection  and  distribution  of  the 
affected  nerves.  How  many  persons  give  us  a  clue  to  the  nature  of  their 
pain  by  fixing  upon  the  nerve  from  which  it  springs  !  Headache,  with 
deepseated  mischief  going  on  within  the  head,  may  involve  the  third  nerve 
at  its  orgin,  and  produces  such  changes  of  the  globe  and  eyelids  as  to  enable 
us  to  recognize  with  certainty  the  exact  seat  of  the  lesion.  As  the  pain  of 
headache  is  referred  to  the  forehead,  the  temples,  or  to  one  side  of  the  head, 
the  fifth  nerve  may  be  taken  as  a  tolerably  accurate  indication  of  the  cause 
of  the  pain ;  so  that,  when  there  is  pain  at  the  back  of  the  head,  it  must  be 
often  due  to  an  affection  of  the  cervical  nerves  and  their  branches.  "  Thus 
pain  in  the  anterior  part  of  the  head  would  suggest  that  the  cause  must  be 
somewhere  in  the  area  of  the  distribution  of  the  other  portions  of  the  fifth 
nerve.  So  if  the  pain  be  expressed  behind,  the  cause  must  as  assuredly  be 
connected  with  the  great  or  small  occipital  nerve,  and  in  all  probability 

*  Symonds  on  Headache. 


SYMPATHETIC    HEADACHE.  49 

depends  on  disease  of  the  spine  between  the  first  and  second  cervical  ver- 
tebrae."* This  is  exactly  the  opinion  we  might  expect  to  receive  from  a 
surgeon ;  for  the  pain  at  the  back  of  the  head  is  not  of  common  occurrence 
in  the  pure  forms  of  idiopathic  headache.  When  the  nervous  system  has 
become  exhausted,  and  the  patient  is  low  and  depressed,  the  occipital  re- 
gion is  more  frequently  affected ;  hence  it  is  common  in  some  cases  of  ner- 
vous headache.  It  is  not  to  be  included  as  a  symptom  among  the  cases  that 
ordinarily  present  themselves  for  advice.  Persons,  however,  may  experience 
periodic  nervous  headache  for  upwards  of  twenty  years,  and  the  pain  on  no 
occasion  extend  behind.  When  pain  is  present  in  this  locality,  it  will  be 
found  to  follow  the  track  of  the  cervical  nerves;  and  the  neck,  from  the  first 
to  the  last  cervical  vertebra,  is  often  tender  and  stiff.  The  pain  extends 
over  the  scalp  at  the  back  of  the  head,  in  the  direction  of  the  occipital 
nerves  and  the  free  anastomoses  which  take  place  between  it  and  the  auricu- 
lar and  temporal  branches  of  the  fifth  nerve.  Now,  I  am  of  opinion  that, 
when  the  occiput  is  the  seat  of  pain  in  headache,  it  may  be  considered  to 
arise  from  an  affection  of  the  cervical  nerves  and  their  occipital  branches,  if 
the  pain  is  superficial  and  the  nervous  sensibility  is  increased ;  but  pain  in 
the  back  of  the  head,  as  we  have  seen,  may  be  owing  to  disease  of  the  spine, 
though  I  apprehend  that  it  can  over  and  over  again  be  ascribed  to  no  other 
cause  than  a  hypereemic  state  of  the  vessels  at  the  posterior  or  under  surface 
of  the  brain  (or  of  the  cerebellum  itself),  where  the  veins  and  sinuses  are  also 
too  full  of  blood,  and  the  nervous  matter  is  deranged  in  consequence. 

Occipital  pain  is  sometimes  present  in  the  headache  of  acute  congestion-, 
and  the  patient  will  even  cry  out  on  any  attempt  being  made  to  move  him, 
or  examine  the  seat  of  suffering.  In  the  case  of  a  gentleman,  aged  twenty- 
eight,  who  came  under  my  care  in  1876,  the  pain  was  described  as  like  the 
beating  of  a  hammer  over  the  greater  portion  of  the  head,  which  was  hot. 
The  pain  at  the  occiput  was  deepseated,  and  limited  to  the  region  of  the 
cerebellum;  the  muscles  of  the  neck  were  also  stiff,  and  the  patient  could 
not  rotate  his  head  in  the  smallest  degree.  The  chief  additional  symptoms 
were  constipation  of  the  bowels,  slight  elevation  of  temperature,  incessant 
vomiting,  and  a  large,  slow,  and  laboring  pulse,  not  exceeding  fifty-two  beats 
per  minute.  I  found  free  purgation  by  calomel,  and  an  open  blister  at  the 
back  of  the  neck,  over  the  upper  cervical  vertebrae,  gave  much  relief.  The 
first  symptoms  of  improvement  were  a  more  frequent  and  natural  pulse,  and 
the  heavy,  throbbing,  deep-seated  pain  changing  its  character,  and  becoming 
paroxysmal  in  the  course  of  the  right  temporal  and  supraorbital  branches  of 
the  fifth  nerve. 

*  Lectures  on  Pain  and  Therapeutic  Influence  of  Mechanical  and  Physiological  Rest,  by 
John  Hilton,  Esq.,  F.  R.  S,,  in  the  Lancet,  vol.  ii.,  i860,  p.  303. 

As  corroborative  of  the  opinion  of  Mr  Hilton,  that  pain  at  the  back  of  the  head  is  some- 
times owing  to  organic  disease,  I  may  briefly  mention  the  case  of  a  consumptive  patient  who 
came  under  my  care  in  1869.  He  suffered  from  the  most  excruciating  pain  at  the  back  of 
his  head,  which  he  could  not  move  for  weeks  together.  About  two  months  before  his  death 
the  pain  abated,  and  he  then  mentioned  to  me  that  his  neck  made  a  grating  noise  when  he 
slightly  rotated  his  head,  which  he  could  now  do  without  causing  any  pain.  After  death 
the  first  and  second  cervical  vertebrse  were  found  carious. 


CHAPTER  IV. 


DYSPEPTIC   OR    BILIOUS    HEADACHE. 


Nature  and  Origin  of — Effect  of  Sympathetic  Action  in  Provoking  Cerebral  Disturbance — 
Functions  of  Pneumogastric  and  Ganglionic  Nerves — Relation  of  Vascular  Excitement  to 
Nervous  Exhaustion — Effects  of  Aperient  Medicines — Stimulating  Drinks  and  Suppers — 
Use  of  Emetics  in  Cuttmg  Short  the  Paroxysm — Alteratives — Alkalies — The  Mineral 
Acids — Quinine — Aconite — Pepsin. 

This  is  also  termed  Sympathetic  or  Sick  Headache  by  some  authorities,  and 
I  think  rightly  so,  because  vomiting  often  dispels  the  pain  like  magic,  the 
source  of  irritation  being  so  removed.  No  headache,  however,  ought  to  be 
termed  bilious,  unless  there  is  so  copious  a  secretion  of  bile  that  it  either 
accumulates  in  the  duodenum  or  regurgitates  into  the  stomach,  or  the  skin  is 
yellow  from  its  absorption  into  the  blood.  Dyspeptic  headache  has  its 
origin  in  imperfect  digestion,  and  arises  either  in  the  stomach  or  duode- 
num, from  the  irritating  and  disturbing  of  the  nervous  apparatus  of  the 
alimentary  canal  by  the  resulting  depraved  secretion.  Indigestion  impresses 
itself  on  the  sensorium  by  sympathetic  action,  and  originates  pain  in  it ;  but, 
though  this  arises  in  a  few  persons  only,  and  not  in  all  whose  habits  are  irreg- 
ular in  eating  and  drinking,  it  must  still  be  accepted  that  there  is  a  tendency 
on  the  part  of  the  nervous  centres  in  the  brain  to  be  so  impressed.  A  morbid 
impression  conveyed  through  the  sympathetic  nerve  to  the  brain  would 
excite  disturbance,  and  act  as  an  agent  of  transmission. 

All  the  processes  of  life  must  be  carried  on  evenly  and  orderly  to  insure 
health.  The  circulation  cannot  continue  with  regularity  unless  digestion  and 
respiration  accord  with  it ;  the  one  is  dependent  on  the  other,  and  the  ner- 
vous connections  of  the  viscera,  if  arrested  or  deranged,  propagate  the  dis- 
turbing element  to  the  cerebro-spinal  system,  through  the  ganglionic  nerves. 
Thus  the  unity  of  the  whole  is  apparent  through  the  intimacy  of  the  physi- 
ological relationships ;  and  when  we  consider  for  a  moment  how  the  action 
of  the  heart  is  disturbed  in  its  functions  by  derangement  of  the  sympathetic 
system,  it  shows  clearly  how  inflammatory  or  other  states  may  originate  dis- 
turbance, and  produce  painful  sensations  in  a  distant  organ. 

The  facts  which  are  proved  concerning  the  functions  of  the  par  vagum  do 
not  warrant  the  drawing  of  any  exact  or  precise  conclusions  from  them. 
What  we  have  to  say,  then,  in  reference  to  the  part  it  plays  in  the  digestive 
process  must  be  to  a  great  extent  uncertain  and  problematical.  It  consists  of 
a  motor  and  a  sensory  tract,  closely  united  together  at  their  origin  in  the 
brain,  the  one  tract  being  destined  for  voluntary,  and  the  other  for  involun- 
tary motion  and  sensation.  This  gives  a  wider  range  of  action,  and  its  dis- 
turbance is  manifested  by  a  variety  of  peculiar  sensations,  from  severe  pain 
on  the  one  hand  to  exalted  sensibility  on  the  other.  Excitation  of  any 
sensory  branch  of  this  compound  nerve,  after  having  reached  the  nervous 
centre,  may  be  reflected  to  any  part  of  the  periphery,  or  even  to  some  part  in 
connection  with  it.  So  closely,  then,  is  one  part  of  this  nerve  associated 
with  other  parts,  that  irritation  experienced  in  any  single  branch  may  be 
conveyed  along  it,  and  felt  in  the  most  distant  portion  of  the  nerve's  peri- 
phery. This  kind  of  irritation,  set  up  by  some  change  or  alteration  in  the 
trunk  or  periphery  of  the  various  sensitive  nerves,  is  analogous  to  those  cases 
of  reflex  paralysis  mentioned  by  Dr.  Brown-Sequard.     Many  paralytic  affec- 

(50) 


DYSPEPTIC    OR    BILIOUS    HEADACHE.  5  I 

tions  (and  especially  paraplegia")  are  due,  not  to  disease  of  the  spinal  cord  or 
its  membranes,  but  simply  to  reflex  irritation,  starting  from  a  sensory  nerve 
or  its  branches,  which  bave  been  irritated  or  excited  ;  and  thus  we  have  cases 
recorded  of  paraplegia  from  the  cutting  of  a  molar  tooth  during  the  second 
dentition  (West,  Kennedy,  Brown-Sequard)  from  enlargement  and  displace- 
ment of  the  uterus,  or  from  ovarian  excitement ;  in  hysterical  paraplegia, 
stricture  of  the  urethra,  and  intestinal  worms.  These  morbid  states  must 
take  place  through  the  medium  of  the  nervous  system,  and  not  through  the 
general  circulation,  or  the  paralysis  would  extend  upwards.  A  case  of  pa- 
ralysis of  the  lower  limbs,  due  to  synovitis,  from  the  extension  of  irrita- 
tion in  the  left  knee-joint,  is  described  by  Brown-Sequard.*  Now,  all  these 
cases  are  caused  by  the  excitation  of  an  afferent  nerve,  and  the  reflex  paraly- 
sis continues  so  long  as  the  excitation  persists.  The  morbid  effect  on  the 
muscles  is  of  a  transient  character,  unlike  the  spasms,  twitching,  and  anaes- 
thesia which  accompany  the  paraplegia  of  myelitis,  where  all  parts  are  in- 
volved, and  the  tendency  of  the  disease  is  towards  a  fatal  termination.  Mr. 
Hilton  has  also  recorded  the  case  of  a  boy  who  was  lame  in  his  right  leg, 
and  could  neither  put  it  to  the  ground  nor  control  its  movements,  yet  the 
real  pathological  cause  was  seated  in  the  brain,  and  not  in  the  limb;  the 
paralysis,  in  fact,  being  nothing  more  or  less  than  a  sympathetic  disorder 
occasioned  by  the  febrile  state.  Mr.  Hilton  has  also  shown  how  the  exact 
seat  of  disease  in  the  hip-joint  may  be  indicated  by  the  spot  on  the  knee 
where  the  pain  is  experienced. 

The  pneumogastric  is  no  exception  to  this  rule,  and  irritation  in  the  stom- 
ach will  often  occasion  a  cough — the  well-known  stomach  cough.  Sir 
Thomas  Watson  relates  the  case  of  an  epileptic,  whose  fits  ceased  with  the 
expulsion  of  a  tape-worm.  "I  know  that  a  physician  of  my  acquaintance 
cured  a  case  of  epilepsy  in  this  way,  somewhat  to  his  own  surprise.  Without 
having  in  his  mind  any  notion  of  worms,  he  thought  it  might  be  well  to  purge 
his  patient,  who  had  labored  under  epilepsy  for  some  time,  with  the  oleum 
terebinth  in  se.  The  patient,  who  is  the  brother  of  a  person  holding  at 
present  a  high  office  in  this  country,  was  residing  two  or  three  miles  out 
of  town.  In  the  middle  of  the  night  the  doctor  was  summoned  to  him  in 
a  great  hurry  ;  the  messenger  said  he  was  supposed  to  be  dying.  He  was 
only  intoxicated,  however,  by  the  free  dose  of  turpentine  that  he  had  swal- 
lowed. The  next  morning  he  voided  into  the  close-stool  a  large  tape-worm, 
and  he  has  hever  had  epilepsy  since.  A  nobleman  residing  in  Cambridge- 
shire was  long  epileptic,  and  he  too  got  rid  of  his  epilepsy  and  of  a  worm  at 
the  same  time."f  Irritation,  then,  at  a  portion  of  the  periphery  of  the 
pneumogastric  may  produce  either  centric  or  peripheral  manifestations. 
The  headache  of  dyspepsia  thus  becomes  intelligible.  Seeing  that  the  nerves 
of  the  stomach  are  derived  from  the  pneumogastric  and  the  sympathetic,  we 
are  in  a  position  to  understand  the  immense  influence  they  must  exert  on  the 
secretions  of  the  viscus.  The  branches  of  the  pneumogastric,  after  perforat- 
ing the  muscular  coat,  ramify  in  the  submucous  areolar  tissue,  until  they  are 
lost  under  the  surface  of  the  mucous  membrane.  "  Each  unites,  not  only 
with  large  and  small  branches  of  its  fellow,  but  with  the  sympathetic  nerves 
of  the  stomach,  at  all  stages  of  their  distribution  visible  to  the  naked  eye — 
from  the  solar  plexus  and  semilunar  ganglia  to  the  secondary  and  tertiary 
offshoots  of  those  around  the  vessels,  and  even  to  their  branches  in  the  areolar 

*  Paralysis  of  the  Lower  Extremities,  by  C.  E.  Brown-Sequard,  M.  D.,  F.  R.  S.,  iS6i, 
page  1 8. 

f  Principles  and  Practice  of  Physic  (4th  edition),  vol.  i.,  page  663. 


52  HEADACHES. 

coat  of  the  stomach. ' '  *  The  distribution  of  the  sympathetic  branches  is  much 
the  same,  and,  after  perforating  the  muscular  coat,  the  plexuses  disappear  in 
the  submucous  tissue,  like  the  gastric  branches  of  the  par  vagum.  The  pneumo- 
gastric  gives  off  branches  which  have  been  traced  into  the  plexus  mesentericus, 
and  so  brought  in  contact  with  the  intestines.  Any  irritation,  then,  of  the 
stomach  and  intestines  may  produce  headache  by  sympathetic  disturbance. 

The  influence  which  the  pneumogastric  nerve  exerts  on  the  action  and  se- 
cretions of  the  stomach  is  both  interesting  and  important,  and  the  subject 
may  well  be  considere'd  in  this  place.  The  extensive  distribution  of  the  par 
vagum,  and  its  intimate  connection  with  the  sympathetic  system,  gives  it  a 
wide  and  diversified  action  ;  it  changes  local  into  general  influences,  and 
possesses  relations  which  involve  distant  organs  in  excitement  and  morbid 
change.  The  pneumogastric  nerve,  both  physiologically  and  pathologically, 
is  never  lost  sight  of  in  any  organic  or  functional  disorder,  and  least  of  all 
should  it  be  so  in  an  affection  like  headache,  when  its  communication  with 
the  brain  and  stomach  is  so  closely  united,  and  the  derangement  of  all  parts 
which  it  supplies  becomes  evident  in  the  painful  sensations  we  experience 
when  it  is  irritated  or  inflamed. 

The  mucous  membrane  of  the  stomach  in  a  healthy  condition  is  of  a  pale 
color  when  at  rest,  but  immediately  an  irritant,  in  the  shape  of  food,  comes 
in  contact  with  it,  the  mechanical  action  induced  by  the  friction  and  motion 
causes  the  vessels  to  dilate,  and  the  surface  to  become  red.  The  thin,  acid, 
transparent,  gastric  secretion  is  poured  out  even  after  the  nervous  supply  is 
cut  off  from  without,  though  it  is  largely  concerned  in  the  secretion,  as  we 
shall  see  in  considering  the  action  of  the  pneumogastric  nerve  on  the  walls 
of  the  stomach  itself  During  fasting,  when  the  stomach  is  at  rest,  there  is 
another  secretion  furnished  by  its  walls,  which  is  thick,  ropy,  and  alkaline. 
The  various  stimulants,  as  ether,  alcohol,  wine  and  spirits,  mustard,  and  a 
host  of  other  excitants,  cause  the  gastric  juice  to  issue  forth  in  abundance 
and  to  perform  a  necessary  part  in  the  digestive  process.  Irritation  of  the 
afferent  sensory  fibres  cause  the  gastric  vessels  to  dilate,  and  the  mucous 
membrane  to  become  reddened,  whilst  Bernard  found  that  section  of  the 
vagi'caused  pallor  of  the  surface  ;  but  it  would  appear  "  that  the  vagus  con- 
tains two  sets  of  afferent  fibres,  one  of  which  increases,  whilst  the  other 
dmiinishes,  the  degree  of  contraction  of  the  gastric  vessels,  "f 

The  close  connection  of  the  par  vagum  with  the  sympathetic  nerve  of  the 
abdomen,  uterus,  and  ovary,  induces  reflex  irritation  in  the  stomach,  which 
is  so  commonly  observed  in  affections  of  these  organs — as  dysmenorrhcea, 
ovaritis,  and  uterine  contraction.  When  the  nerve  is  divided  or  injured, 
any  of  the  parts  to  which  it  is  supplied  may  be  affected,  as  violent  or  spas- 
modic action,  retarded  motion  of  the  heart,  or  congestion  or  inflammation. 
Irritation  of  the  gastric  branches  induces  vomiting,  but  section  arrests  it, 
and  causes  distension  of  the  viscus. 

As  the  par  vagum  is  in  immediate  relationship  with  the  chief  cerebral 
nerves  fthe  glosso-pharyngeal,  the  fifth,  the  seventh,  the  third,  the  ninth, 
and  spinal  accessory),  we  may  in  a  great  measure  realize  how  its  sympathetic 
disturbance  may  involve  organs  which  own  a  different  nerve-supply,  and  are 
only  brought  into  relation  with  it  through  nerve  inosculations.  The  union 
of  the  par  vagum,  therefore,  with  other  nerves  may  set  up  far  away  reflex 
irritation,  as  we  have  seen,  but  more  particularly  with   the  fifth,  and  with 

*Brinton  on  Diseases  of  the  Stomach,  1864,  p.  24. 

f  See  The  Action  of  the  Vagus  on  the  Stomach,  by  Dr.  Lauder  Brunton,  in  Handbook 
for  the  Physiological  Laboratory  (Text  1873),  page  493. 


DYSPEPTIC    OR    BILIOUS    HEADACHE.  53 

that  state  of  irritability  and  supraorbital  pain  which  we  have  seen  to  follow 
the  introduction  of  ice  into  the  stomach.* 

The  alliance  of  the  par  vagum  with  the  ganglionic  supply  to  the  stomach 
enables  us  to  judge  of  their  continued  effects  upon  the  pulse  and  cardiac  cir- 
culation ;  in  many  acute  diseases  the  cardiac  plexus  and  the  solar  plexus  are 
brought  into  close  and  immediate  sympathy,  which  is  inseparable  between 
them.  The  diseases  of  the  stomach  and  abdominal  viscera  produce  their  full 
share  in  prostrating  the  vital  powers,  rendering  the  pulse  imperceptible,  and 
causing  coldness  of  the  surface  and  syncope.  No  better  illustration  can  be 
found  than  the  effect  which  a  disturbed  stomach  or  a  severe  bilious  attack  has 
on  the  cardiac  circulation,  when  the  nervous  power  is  exhausted  and  the 
vessels  are  weak  and  dilated.  Hence  it  is  that  the  healthy  action  of  this 
nerve  is  essential  for  the  steady  performance  of  the  digestive  process  ;  and, 
when  digestion  fails,  the  nerve-power  will  frequently  be  found  at  fault.  If  the 
strength  of  the  constitution  has  been  reduced  from  prolonged  indulgence 
in  alcoholic  stimulants,  the  nervous  energy  is  the  more  exhausted,  and  as  the 
patient  cannot  assimilate  sufficient  food  to  keep  the  functions  of  life  going 
steadily,  the  way  is  paved  for  chronic  dyspepsia  and  degenerative  changes. 

The  secretion  of  gastric  juice  is  affected  by  the  state  of  the  nervous  sys- 
tem, and  sudden  mental  emotion  is  able  to  stop  it  altogether.  The  channel 
by  which  this  is  conveyed  clears  up  any  doubt  or  mystery  attaching ^to  the 
phenomena ;  for  the  division  of  the  trunk  of  the  pneumogastric  controls  the 
secretion  of  gastric  juice  and  the  movements  of  the  stoinach.  Though  the 
experiments  of  physiologists  like  Reid,  Schiff,  Budge,  Longet,  Bernard, 
Ravitsch,  etc.,  show  that  the  stomach  gradually  recovers  its  lost  tone  after 
division  of  the  par  vagum,  the  functions  of  absorption  and  assimilation  are 
enfeebled  for  a  considerable  length  of  time.  The  division  of  the  sym- 
pathetic nerves,  also,  does  not  arrest  the  functions  of  this  organ.  But  con- 
tinued disorder  of  one  or  other,  or  of  both  these  nerves,  apart  from  any  ex- 
perimental deduction,  proves,  I  think,  to  demonstration,  that  when  pain  is 
suddenly  experienced  at  the  pit  of  the  stomach  from  the  reception  of  bad 
news,  they  are  so  affected  as  to  exert  a  most  important  influence  on  the  di- 
gestive apparatus.  The  failure  of  nervous  power  is  obvious  enough  in  the 
fearful  gastralgia  and  feeble  digestion  that  render  the  life  of  some  people  a 
burden,  and  I  do  not  think  that  even  the  division  of  the  par  vagum  at  the  oeso- 
phageal opening  or  of  the  splanchnics  in  the  abdomen  of  the  lower  animals 
without  palpable  and  permanent  effect  on  the  digestive  powers,  justifies  us  in 
setting  at  naught  the  agency  of  the  nervous  system  in  man,  and  still  more  the 
importance  of  the  pneumogastric  in  the  production  of  reflex  phenomena. 

A  genuine  bilious  headache  is  less  common  among  women  than  men, 
who  commit  greater  excesses  in  eating  and  drinking.  Young  people  of  both 
sexes  are,  however,  liable  to  it.  The  pain  comes  on  in  the  morning  after  a 
heavy  meal  the  night  before,  or  after  drinking  too  much  wine;  or  it  succeeds 
a  heavy  midday  meal,  if  the  person  is  not  accustomed  to  it;  or  if  the  food 
is  hurriedly  eaten,  and  exertion  and  fatigue  follow  it.  The  pain  occupies 
the  whole  forehead  and  top  of  the  head,  which  feel  hot  and  sometimes 
burning.  The  face  is  flushed,  and  the  temporal  arteries  throb.  A  heated 
room,  or  stooping,  brings  on  extreme  nausea,  and  aggravates  the  suffering. 
If  the  patient  avoid  taking  food  he  may  manage  to  get  through  the  business 
of  the  day,  but  when  evening  arrives  if  he  attempts  to  eat  the  pallid  face  is 
exchanged  for  one  of  vascular  excitement,  and  the  throbbing  headache  often 
culminates  in  a  violent  attack  of  vomiting,  after  which,  when  the  hope  of 

*See  Chaper  III,  on  Sympathetic  Headache. 


54  HEADACHES. 

alleviation  has  departed,  he  suddenly  and  unexpectedly  falls  asleep,  and 
awakes  next  morning  well.  An  attack  of  severe  retching,  with  or  without 
the  discharge  of  frothy  mucus  and  bile  from  the  stomach,  will  sometimes 
remove  the  fit  of  suffering.  Its  duration  varies  from  a  few  hours  to  three  or 
four  days.  In  some  patients  it  frequently  continues  a  week,  and  the  first  sign 
of  amendment  is  a  desire  for  food  with  the  power  to  digest  it.  After  the 
long  continuance  of  severe  gastric  headaches,  the  vascular  excitement  gives 
place  to  ner\'0us  exhaustion,  and  as  they  become  more  frequent,  the  nervous 
element  preponderates,  so  that  with  the  advance  of  years  the  bilious  character 
and  the  vomiting  are  exchanged  for  the  type  of  headache  which  we  shall 
presently  describe.  But  one  form  of  headache  during  its  continuance  may 
partake  of  the  character  of  several  types.  That  which  begins  as  a  purely 
bilious  may  end  as  a  nervous  headache,  and  that  which  begms  as  a  nervous 
may  terminate  as  a  bilious  headache,  so  great  is  the  sympathy  between  the 
stomach  and  the  brain.  Where  the  urine  is  turbid  and  high-colored,  and 
the  complexion  sallow,  the  cause  may  be  traced  in  many  instances  to  an 
accumulation  of  bile  in  the  duodenum  or  the  blood,  and  a  fit  of  vomiting 
will  sometimes  cause  a  large  quantity  to  be  ejected  by  the  stomach. 

Whatever  the  exact  cause  and  nature  of  the  headache  may  be,  the  nervous 
system  has  largely  to  do  with  it,  inasmuch  as  some  persons  of  the  most 
irregular  habits,  with  defective  depurative  organs,  never  have  the  sensation 
of  a  headache.  I  once  knew  a  gentleman  who  Avas  a  martyr  to  gout,  and 
had  attacks  which  confined  him  to  bed  for  six  weeks  at  a  time,  and  whose 
secretions  were  much  deranged,  as  was  shown  by  the  dark  bilious  character 
of  the  evacuations,  high-colored  urine,  and  foul  tougue  :  yet  this  patient, 
who  freely  indulged  in  the  pleasures  of  the  table,  and  drank  largely  of  wine, 
never  within  his  knowledge  felt  the  sensation  of  a  headache.  He  was, 
however,  one  of  the  most  nervously  timid  persons  I  ever  met  with,  shunning 
the  society  of  ordinary  visitors,  and  at  times  he  could  not  summon  up 
sufficient  courage  to  meet  his  oldest  friends. 

Causes. — The  habit  of  continually  taking  aperient  medicines  by  which  the 
powers  of  digestion  are  enfeebled,  indulgence  in  indigestible  food  and  stim- 
ulating drinks,  are  common  causes  of  this  headache.  A  glass  of  beer,  or  a 
teaspoonful  of  brandy,  will  bring  it  on  at  any  time  in  those  persons  who  are 
predisposed  to  it,  and  where  the  digestive  organs  are  easily  deranged.  Sup- 
pers, if  persons  are  not  accustomed  to  them,  will  cause  disturbed  sleep,  fol- 
lowed by  heat  of  the  head,  extreme  nausea,  and  headache  on  awaking.  Some 
of  the  worst  forms  of  this  headache  have  followed  the  excitement  of  evening 
parties,  and  the  overloading  of  the  stomach  with  indigestible  food.  Un- 
wholesome food,  which  temporarily  disturbs  or  arrests  digestion,  will  occa- 
sion acute  dyspepsia  in  some  persons,  and  such  persons  are  extremely  prone 
to  this  form  of  headache  ;  uneasiness  at  the  stomach,  faintness,  depression  of 
spirits,  lassitude,  and  febrile  excitement,  are  to  be  reckoned  among  the  pro- 
dromata.  Then  succeeds  an  oppressive  frontal  headache,  with  nausea  and 
inability  to  face  the  light,  or  bear  the  slightest  noise.  In  some  persons  vom- 
iting ensues,  and  the  patient  finds  immediate  relief;  and  in  others  colicky 
pains  and  diarrhoea  expel  the  irritating  matters  from  the  intestines,  and  the 
patient  loses  the  headache  more  gradually ;  weight  about  the  praecordia,  dis- 
like of  food,  high-colored  urine,  offensive  evacuations,  and  a  creamy  fur  on 
the  tongue  may  remain  for  days  after,  during  which  the  nervous  system  is 
more  or  less  implicated,  and  confusion  of  ideas  and  vertigo,  with  a  return  of 
throbbing  headache,  follow  any  employment  of  the  mind  requiring  thought 
and  reflection.  This  headache  may  come  on  in  a  few  hours  after  food,  or 
the  patient  may  go  to  bed  comfortably,  and  either  have  disturbed  and  rest- 


DYSPEPTIC    OR    BILIOUS    HEADACHE.  55 

less  sleep,  or  wake  up  unrefreshed  with  a  weight  across  the  forehead,  and 
forthwith  the  affection  begins  in  earnest.  A  sense  of  cold  and  chilliness  is 
felt  about  the  scalp  and  face  for  a  few  hours,  particularly  if  nothing  is  put 
into  the  stomach ;  but  if  such  be  the  case,  or  as  the  day  advances,  the  face 
becomes  hot  and  flushed,  and  the  patient  is  continually  employed  in  apply- 
ing cold  wetted  rags  to  the  head  for  relief. 

"  The  headache  which  appears  in  the  course  of  the  slighter  attacks  of  this 
nature,  often  assumes  a  form  with  somewhat  characteristic  features,  and  which 
is  familiarly  known  as  the  'sick  headache.'  It  is  most  common  when  acute 
exacerbations  are  superadded  to  the  ordinary  forms  of  atonic  dyspepsia ;  and 
hence  it  is  most  liable  to  affect  those  who  are  out  of  health,  and  whose  diges- 
tions are  weakened  by  sedentary  employment,  and  who  have  a  tendency  to  cos- 
tiveness.  It  occurs,  however,  also  in  persons  of  apparently  vigorous  health, 
sometimes  without  apparent  cause,  but  most  usually  after  some  indiscretion  in 
diet,  or  after  some  of  the  causes  most  likely  to  arrest  the  digestive  process."* 

Treat^nent. — In  early  life,  when  this  headache  is  threatening,  it  can  al- 
ways be  traced  to  some  error  in  diet,  and  an  emetic  of  sulphate  of  zinc  or 
ipecacuanha  brings  relief  in  a  couple  of  hours  (Form.  108-109);  or  one 
grain  of  calomel,  or  three  grains  of  blue  pill  taken  on  an  empty  stomach 
will  mitigate  the  suffering  in  the  head,  though  it  may  increase  the  nausea 
and  loathing  of  food.  With  the  advance  of  years  these  headaches  become 
less  acute,  but  more  exhausting  and  tedious  in  their  recovery.  Rest  in  bed, 
cold  applications  to  the  head,  and  an  alterative  pill,  followed  by  an  alkaline 
purge  in  the  morning,  suffice  for  their  cure  (Form.  81-19). 

When  patients  are  very  bilious,  and  the  conjunctivae  yellow,  a  good 
cholagogue  purgative  (Form.  79)  will  excite  the  action  of  the  liver,  and 
drain  away  a  copious  quantity  of  bile.  A  mixture  of  soda  and  bismuth  with 
sal  volatile  will  be  useful  to  relieve  flatulency  and  acidity  (Form.  15). 
Where  the  bowels  are  irritable,  a  full  dose  of  bismuth  twice  a  day  before 
meals  is  good  (Form.  107).  In  the  case  of  persons  who  are  not  strong,  a 
few  grains  of  carbonate  of  ammonia  in  water  (Form.  16),  or  sal  volatile,  and 
chloric  ether,  will  sometimes  arrest  the  symptoms  at  once  (Form.  17). 

If  the  headache  is  accompanied  with  atonic  dyspepsia,  and  there  is  a  clean 
tongue  with  weight  and  oppression  at  the  epigastrium,  the  nitro-muriatic  acid 
will  be  found  serviceable  before  meals  twice  or  three  times  a  day  (Form. 
48).  If  flatulence  is  very  troublesome,  bismuth  with  nux  vomica,  and  if 
there  is  constipation,  a  morning  pill  of  aloes,  nux  vomica,  and  belladonna, 
or  one  consisting  of  aloes,  capsicum,  quinine,  and  ipecacuanha,  are  indicated 
(Form.  77-78).  In  some  varieties  of  dyspeptic  headache,  Dr.  Smith  gives 
one  minim  of  the  tincture  of  nux  vomica  every  fifteen  minutes  for  two  or 
three  hours,  and  he  has  found  it  most  effectual.  Where  the  extremities  have 
been  cold,  and  the  pulse  small  and  hard,  a  drop  of  tincture  of  aconite  in  a 
teaspoonful  of  water  has  fully  answered  my  expectations  in  many  instances. 
By  dilating  the  vessels  and  favoring  perspiration  it  has  wonderfully  relieved 
the  aching  brain.  If  the  headache  comes  on  soon  after  a  meal  from  slow- 
ness of  digestion.  Dr.  Smith  gives  half  a  drachm  of  saccharated  pepsin  in  a 
wineglassful  of  sherry  three  times  a  day  at  meal-times. f  I  have  given 
Morson's  pepsin  wine  with  great  advantage  at  meals,  and  it  certainly 
accelerates  digestion  and  relieves  nausea  and  gastric  oppression. 

*  On  Acute  Gastric  Catarrh,  by  Wilson  Fox,  M.  D.,  F.  R.  S.;  A  System  of  Medicine, 
edited  by  J.  Russell  Reynolds,  M.  D.,  F.  R.  S.,  vol.  ii.,  1872,  p.  869. 

f  The  Therapeutics  of  Headache,  by  A.  A.  Smith,  M.  D.  A  Lecture  deUvered  at  tlie 
Bellevue  Hospital  Medical  College,  in  Medical  Record,  September  15th,  1876,  p.  390. 


CHAPTER  V. 

CONGESTIVE    HEADACHE. 

Physiological  Distinctions  between  Congestion  and  H}-per8emia — Definition  of  the  two 
States — True  Congestive  Headache  is  of  a  Passive  Character — Seat  of  Pain  and  General 
Symptoms — Causes  that  invite  Congestive  Headache — Good  Living — Sedentary  Habits 
— Bronchits — Asthma^ — ^Yhooping- cough — Tight  Stays  and  whatever  impedes  the  Circula- 
lation — Treatment  consists  in  lessening  the  supply  of  Blood  to  the  Brain  when  in  excess, 
and  promoting  its  circulation  through  the  Vessel  when  their  Tonicity  is  impaired — Purga- 
tives—  Saline  Waters — Occasional  Advantage  of  Venesection — Spare  Diet  and  Avoidance 
of  Stimulants  in  the  Active  Form — Counter-irritation — Walking  Exercise — Change  of  Air 
— Foreign  Watering-places — Aconite — Bromides  of  Potassium  and  Ammonium — Strych- 
nia— Nux  Vomica — Mild  Preparations  of  Iron  in  Ansemic  Cases. 

In  the  active  variety  this  can  scarcely  be  separated  from  the  headache  of 
active  hyperemia.  It  overlaps  each  of  the  other  forms,  active  and  passive 
hypersemia  ;  yet  it  is  not  absolutely  either.  Congestion  seems  rather  to  be 
a  dilated  condition  of  the  minute  vessels,  arterioles,  capillaries,  and  venules, 
owing  probably  to  some  modification  of  the  textures  of  the  brain,  by  which 
they  attract  more  blood  to  themselves  than  they  do  in  health.  In  active 
hyperaemia,  or  one  form  of  it,  the  determination  of  blood  is  more  sudden 
and  energetic,  and  the  symptoms  violent  for  the  time  it  lasts ;  the  tempera- 
ture is  higher,  and  the  pulse  quicker  and  stronger.  The  patient  feels  the 
whole  arterial  system  throb  and  pulsate.  As  another  and  marked  distinction 
from  any  form  of  congestion,  the  nervous  centres  are  more  susceptible,  and 
this  has  a  very  determining  influence  on  the  vascular  system,  rousing  the 
circulation  more  violently  than  in  congestion,  and  increasing  the  functional 
activity  of  the  affected  part.  Vital  power  and  action  are  increased,  with  a 
less  tendency  to  produce  inflammation.  It  is  a  form  of  hypersemia  that  does 
not  lead  to  inflammation.  The  sensibility  is  heightened  in  proportion  to  the 
increased  supply  of  blood. 

Congestive  headache  occurs  most  frequently  in  plethoric  persons,  and 
those  of  full  habit  of  body ;  but  it  may  happen  to  those  who  have  a  sluggish 
brain  circulation,  and  in  whom  the  vessels  are  habitually  loaded.  It  is  the 
form  of  headache  that  occurs  at  the  commencement  of  febrile  disorders, 
acute  hydrocephalus,  and  threatening  apoplexy ;  but  in  these  latter  cases  it 
attracts  less  notice  and  consideration  than  the  primary  disease  on  which  it 
depends,  and  is  therefore  to  be  considered  as  a  secondary  rather  than  as  a 
primary  aff"ection.  In  its  true  signification  it  is  a  passive  congestive  form  of 
headache,  depending  on  fulness  of  the  vessels  of  the  brain,  and  there  is  no 
better  example  than  that  which  follows  an  epileptic  seizure.  I  have  met 
with  it  in  country  people  who  lead  an  active  life  and  are  of  regular  habits. 
Bilious  and  lymphatic  temperaments  are  liable  to  this  affection  ;  the  face  be- 
comes bloated,  the  eyes  heavy,  and  the  conjunctivae  injected ;  the  expression 
is  heavy  and  sad,  and  the  pulse  full  and  soft,  or  weak,  small,  and  accelerated. 
The  symptoms  are  a  dull  and  severe  pain,  extending  from  the  forehead  to 
the  occiput,  and  great  heaviness  and  stupor;  the  suffeiing  is  rather  limited 
than  general,  and  is  sometimes  referred  to  a  particular  part  of  the  head, 
which  indicates  congestion  of  one  lobe  or  hemisphere  of  the  brain ;  the  pa- 
tient is  apathetic  and  indifferent,  and  suffers  from  giddiness  and  noises  in 
the  ears.     If  he  stoop  or  turn  round  quicklv,  he  experiences  the  disagreeable 

(56) 


CONGESTIVE    HEADACHE.  57 

sensation  of  vertigo;  his  walk  is  apt  to  be  overcautious,  and  his  nervous 
system  is  tremulous  and  susceptible.  In  persons  who  are  advancing  in  life, 
hypochondriacal  symptoms  are  of  common  occurrence,  and  the  nights  are 
restless  and  disturbed  by  frightful  dreams.  If  the  pain  continues  long,  and 
does  not  yield  to  treatment,  the  patient  loses  strength,  is  depressed,  and 
easily  fatigued  ;  the  pulse  is  irregular  in  force  and  frequency,  and  there  may 
be  palpitation  and  shortness  of  breath.  The  appetite  is  generally  good,  and 
the  tongue  clean  and  red,  but  the  bowels  are  disposed  to  be  costive,  and  the 
urine  torpid  and  high-colored.  This  form  of  headache  is  said  by  some 
writers  to  occur  in  irritable  and  anaemic  subjects,  but  I  cannot  say  that  I 
have  frequently  observed  it  in  this  class  of  persons.  When  it  does  occur  in 
these  states  of  constitution,  the  pulse  is  weak  and  frequent ;  there  are  flashes 
of  light  before  the  eyes,  the  skin  is  pale,  and  the  tongue  generally  clean  and 
bloodless.  Sometimes  weakly  persons  suffer  from  a  dull  continuous  head- 
ache, during  which  the  heart's  action  is  violent,  and  the  carotid  and  tem- 
poral arteries  throb ;  but  if  congestion  of  the  vessels  of  the  brain  exist,  pain 
comes  on  in  paroxysms,  from  sudden  noise  or  exertion,  and  is  transitory  in 
its  duration.  An  oversensitive  condition  of  the  nerves,  by  causing  a  hyper- 
semic  state  of  the  vessels  of  the  brain,  analogous  to  the  distension  of  the  cap- 
illaries in  blushing,  may  induce  it. 

The  true  headache  of  active  congestion  belongs  to  a  general  hyperaemic 
condition,  and  there  is  an  excess  of  blood  in  the  system,  or  it  is  propelled 
with  an  increased  activity,  which  overexcites  the  cerebral  tissues  and  causes 
pain.  But  in  passive  congestive  headache  the  circulation  is  at  fault,  and  the 
tone  of  the  system  is  deficient.  Cases  are  often  seen  where  the  patient  is 
nervous  and  weak,  the  expression  heavy,  and  the  face  sallow  and  bloodless. 
The  spirits  are  dejected,  and  the  drooping  eyes  bespeak  a  sad  and  sorrowful 
condition  of  the  mind.  The  blood  is  not  propelled  through  the  cerebral 
vessels  with  sufficient  activity  or  force,  in  consequence  of  their  imperfect 
contractility,  and  hence  they  become  overloaded  without  any  extra  power  to 
propel  their  contents  onwards.  In  malarial  poison,  congestion  of  the  brain 
is  common,  like  that  of  the  spleen  and  liver;  the  blood  moves  slowly,  and 
the  vessels  are  enlarged  and  distended  in  consequence  of  a  loss  of  tone. 

Cases  of  meningitis  are  recorded  which  prove  that  there  is  no  necessary 
connection  between  the  locality  and  degree  of  headache  and  the  inflamma- 
tory lesion.  Headache  must  therefore  have  an  independent  existence,  and 
owe  little  to  actual  disorganization  of  structure.  For  organic  change  may 
cause  congestion — a  condition  brought  about  by  very  opposite  causes,  as 
overexertion,  mental  distress,  and  debility  of  the  vessels  through  which  the 
blood  is  conveyed.  Many  cases  of  headache  attributable  to  cerebral  conges- 
tion can  find  "no  other  explanation.  Now,  this  congestion  seems  to  be  borne 
longer  with  impunity  by  a  sensitive  organ,  like  the  brain,  than  by  any  other 
tissue,  where  it  would  lead  to  excess  of  secretion  or  alteration  of  structure. 
The  functions  of  the  brain  are  altered  (though  it  escapes  injury),  chiefly 
through  functional  disturbance  of  the  nerves  themselves,  which  may  or  may 
not  produce  an  alteration  in  the  vessels.  The  nerves  in  the  form  of  head- 
ache are  first  involved,  and  any  mental  excitement  will  cause  their  disturb- 
ance; and  as  the  bloodvessels  are  in  close  and  intimate  relation  with  them, 
the  capillary  circulation  quickly  responds,  and  produces  a  state  of  hypersemia. 
Under  any  degree  of  emotion  these  headaches  are  common  enough,  and  the 
flushing  of  the  vessels  of  the  face  and  neck  indicates  how  they  become  over- 
loaded under  passion,  or  any  kind  of  mental  disturbance.  The  vehemence, 
again,  of  invective  oratory,  under  a  strain  of  deep  thought  and  reasoning, 
excites  the  action  of  the  heart,  and  forces  the  blood  to  the  cerebral  circula 
4 


58  HEADACHES. 

tion,  where  it  is  detained,  and  keeps  up  the  cerebral  excitement.  There  are 
many  persons  (and  it  is  especially  so  with  nervous  and  irritable  children)  in 
whom  intellectual  exertion  brings  on  a  state  of  active  congestion,  which 
prevents  them  from  following  their  work;  and  if  it  is  persisted  in,  changes 
may  then  ensue  in  the  vesicular  structure  of  the  brain,  which  permanently 
damage  or  impair  it.  I  possess  notes  of  cases  of  fatal  congestion  of  the 
brain  and  meningitis,  in  children  after  a  few  days'  illness.  In  each  instance 
the  attacks  were  preceded  by  slight  headache  and  sickness;  but  setting  aside 
this  significant  symptom  of  brain  mischief  in  early  life,  the  other  indications 
of  failing  health  were  too  trivial  to  have  given  warning  of  the  grave  results 
to  follow. 

Causes. — The  causes  that  invite  congestive  headache  are  a  peculiar  con- 
figuration of  the  body,  such  as  when  the  chest  is  capacious,  the  shoulders 
high,  and  the  neck  short ;  or  again  when,  as  with  many  persons,  there  is  a 
general  redness  of  the  skin  and  lips.  The  patient  experiences  shortness  of 
breath  in  going  upstairs,  and  is  distressed  with  exertion.  He  is  fond  of 
good  diet  and  stimulating  drinks,  and  prefers  sleep  and  sedentary  habits  to 
active  exertion  and  scanty  fare.  This  headache  in  its  active  form  is  not 
un frequently  seen  in  young  healthy  womeix,  whose  catamenial  losses  have 
been  suddenly  suppressed  through  taking  cold."^  Whatever  depresses  the 
bodily  powers  and  reduces  the  general  strength,  exhausts  the  system  and 
induces  debility  of  the  vessels,  favors  congestion,  and  relaxes  their  tonicity 
and  contractility.  It  is  seen  in  both  sexes  when  the  constitution  is  broken 
down  and  shattered  by  indulgence,  and  in  stout  heavy  persons,  who  have 
had  attacks  of  bronchitis  and  asthma ;  in  wonien  who  have  borne  large 
families,  and  whose  nervous  power  is  exhausted.  During  or  after  whooping- 
cough  it  is  not  uncommon  when  the  attacks  of  spasm  are  violent,  and  the 
pulmonary  complication  is  tedious  and  irksome.  Persons  who  play  the 
cornet,  and  other  instruments  requiring  prolonged  ex;piratory  efforts,  and  the 
suspension  of  the  breath  for  some  seconds,  are  frequent  sufferers.  The  now 
happily  discarded  stock  worn  by  our  soldiers  a  few  years  ago  induced  this 
variety  of  headache;  and  any  constriction  about  the  neck,  or  the  use  of  tight 
stays  to  compress  the  figure  into  a  fashionable  shape,  will  bring  about  the 
same  evil  by  impeding  the  circulation. 

Organic  change  may  induce  it,  by  disturbing  the  relations  of  the  structures 
of  the  brain,  and  causing  congestion  and  interference  with  the  circulation. 
Congestive  headache  of  a  passive  character  is  exemplified  in  hypertrophy  and 
valvular  disease  of  the  heart,  where  we  may  frequently  witness  lividity  of  the 
features,  distension  of  the  jugular  veins,  coldness  of  the  skin,  and  fulness  of 
the  temporal  vessels.  In  a  little  girl,  aged  ten  years,  who  was  under  my 
care  with  this  form  of  heart  affection,  the  headache  was  nearly  unceasing, 
and  the  poor  child  only  got  relief  by  a  free  purgative  and  the  lightest  diet. 
The  brain  was  overloaded  with  blood  from  passive  congestion,  and  the  blood 
interrupted  in  its  return  by  the  condition  of  the  heart.  Indeed,  it  appears 
to  me  that  it  is  impossible  to  dissociate  congestion  of  the  vessels  from  any 
form  of  headache  in  some  stage  of  its  progress.  The  purely  nervous  head- 
ache in  many  persons,  at  its  commencement,  or  shortly  after,  exhibits  signs 
of  congestion  in  the  frequency  and  fulness  of  the  pulse,  the  warmth  of 
surface,  the  heat  of  the  head  and  scalp,  the  tendency  to  vomit,  in  constipa- 
tion, and  in  a  greater  or  less  degree  of  paralysis  of  all  the  functions.  As  the 
circulation  of  the  brain  is  active,  and  the  amount  of  blood  within  it  is  at  all 
times  great,  even  in  health,  we  may  reason  from  analogy  that  the  nerves  are 

*  See  Chapter  VI.,  on  Plethoric  Headache. 


CONGESTIVE    HEADACHE.  59 

exceedingly  liable  to  disturbance  in  those  who  are  subject  to  headache, 
because  it  is  possible,  and  not  uncommon,  for  persons  to  have  habitually  a 
congested  and  sluggish  circulation  through  the  brain  and  other  cavities  of 
the  body,  without  experiencing  the  sensation  of  a  headache. 

Repeated  epileptic  seizures  will  also  induce  severe  congestive  headache. 
The  headache  which  happens  to  the  intemperate  and  those  addicted  to 
irregular  habits  is  of  the  congestive  and  hypersemic  variety.  The  vessels  of 
the  brain  are  overloaded  by  the  entrance  of  alcohol  into  the  blood  ;  there  is 
congestion  of  the  stomach  and  of  the  liver  also,  these  latter  organs  being 
first  in  fault.  A  hypersemic  condition  of  the  arteries  of  the  brain,  arising 
from  a  diminution  in  the  tonicity  of  the  vessels,  and  causing  severe  head- 
ache, is  not  uncommon  in  those  persons  who  exhaust  the  brain  by  prolonged 
study,  and  excessive  intellectual  exertion.  The  brain  is  fagged,  and  never 
rested  long  enough  for  the  vessels  to  recover  their  tone  and  vigor.  Men  of 
the  strongest  intellect  and  the  most  placid  natures,  when  afflicted  with  this 
headache,  become  dejected  and  irritable,  and  exhibit  traits  of  character 
which  they  have  not  previously  shown,  and  difficulty  is  felt  in  concentrating 
the  mind  on  work ;  while  the  patient,  if  accustomed  to  walk  vigorously, 
now  finds  that  short  distances  tire  him.  He  first  has  an  uncomfortable 
feeling  of  pressure  along  the  front  and  top  of  his  head— an  uneasy  sensation, 
similar  to  what  is  felt  from  extreme  heat  or  cold.  Later  on,  the  headache  is 
characterized  by  a  heavy  pain  across  the  frontal  region,  dull  and  continuous. 
This  is  often  succeeded  by  faintness  and  inability  to  walk.  When  talking, 
there  is  a  sensation  of  weight  over  the  brain,  and  numbness  of  the  scalp.  In 
short,  the  brain  is  being  worn  out ;  and  if  this  continues,  there  is  certainty 
of  the  patient  sooner  or  later  breaking  down  altogether.  Long-continued 
anxiety  and  the  srruggles  of  professional  life,  hopes  disappointed  and  plans 
frustrated,  will  induce  a  state  of  congestion  or  hypersemia  of  the  brain  and 
headache,  which  may  become  permanent,  if  the  warning  is  not  taken  in 
time ;  for  when  the  brain  is  constantly  overcharged  with  blood,  changes  in 
the  vesicular  structure  of  the  nervous  matter  are  not  unlikely  to  occur,  which 
sometimes  end  in  weakness  of  intellect. 

Treatment. — In  managing  this  variety  of  headache,  the  local  as  well  as 
the  constitutional  symptoms  must  be  carefully  estimated.  It  will  be 
necessary  to  inquire  into  the  condition  of  the  capillaries  of  the  brain,  and 
whether  the  blood  is  impeded  in  its  passage  through  the  circuitous  veins  and 
sinuses  of  the  cranium.  The  age  of  the  patient  and  the  habits  of  his  life  will 
also  demand  careful  consideration,  before  we  can  submit  him  to  treatment 
with  any  prospect  of  relief.  In  the  plethoric  and  robust,  the  quantity  of 
blood  circulating  through  the  brain  may  be  lessened  by  exciting  the  action 
of  the  secreting  organs.  A  full  dose  of  calomel  and  colocynth  should  be 
given  at  bedtime  occasionally,  and  a  saline  aperient  during  the  day  (Form. 
80).  A  tumblerful  of  Apollinaris  water,  on  going  to  bed,  will  stimulate  the 
bowels  to  act  more  freely  on  the  following  morning,  and  cool  and  refresh 
the  system.  About  twice  a  week,  according  to  the  circumstances  of  the 
case,  two-thirds  of  a  tumblerful  of  Friedrichshalle  water,  in  a  little  lukewarm 
water,  taken  on  rising,  will  prove  a  mild  and  efficient  purgative,  and  it 
answers  exceedingly  well  in  these  cases. 

The  diet  should  be  spare,  and  beer  and  spirits  abandoned.  Active  exercise 
in  the  fresh  air,  and  habits  of  early  rising,  should  be  enforced  ;  and  these 
measures,  when  rigorously  carried  out,  afford  the  best  promise  of  relief. 

Bloodletting,  either  general  or  local,  is  rarely  if  ever  needed ;  it  being  pre 
ferable  to  trust  to  abstinence,  mild  or  active  exercise  in  the  open  air,  and 
due  attention  to  the  action  of  the  liver  and  bowels.     In  the  case  of  young 


60  HEADACHES. 

plethoric  women  I  have  known  leeching  the  temples  or  groin  prove  advan- 
tageous. There  are  instances  occasionally  to  be  met  with,  however,  where 
the  patient  is  indolent  and  overfed,  besides  being  too  full  o^  blood  already. 
He  is  about  the  middle  period  of  life,  and  is  much  averse  to  exertion  or 
active  employment  of  any  kind.  His  habits  of  life  having  become  sedentary, 
it  happens  probably  that  the  bowels  no  longer  act  so  freely,  the  liver  being 
habitually  congested,  and  the  circulation  through  it  to  some  extent  obstructed. 
Cases  of  this  character  may  possibly  be  benefited  by  the  abstraction  of  blood, 
but  even  here  brisk  cathartic  and  alterative  medicines  are  most  to  be  relied 
on  (Form.  79-80-29).  In  one  case  that  came  under  my  notice,  much  bene- 
fit was  derived  from  an  open  blister  at  the  back  of  the  neck  ;  but  no  meas- 
ures will  be  availing  unless  the  diet  is  restricted,  and  exercise  is  regularly 
taken  in  the  open  air. 

In  some  cases  of  acute  congestive  headache,  where  the  face  is  hot  and 
flushed,  the  pulse  firm,  and  the  skin  dry,  the  antiphlogistic  effects  of  aconite 
prove  of  signal  service,  by  inducing  diaphoresis,  and  relaxing  or  partially 
paral)^zing  the  vasomotor  system  (Form.  26  a).  Aconite  depresses  the 
heart's  action,  and  by  reducing  arterial  excitement,  and  diminishing  pres- 
sure and  tension  in  the  vessels,  it  controls  the  amount  of  blood  which  circu- 
lates through  the  cerebral  mass.  The  patient  should  lay  his  head  on  a  hard 
and  elevated  pillow,  and  either  the  ice-cap,  or  some  other  means  of  produc- 
ing cold,  should  be  continually  applied  to  it,  till  the  pain  becomes  less 
severe. 

When  this  headache  is  the  result  of  overwork  of  the  brain  and  prolonged 
study,  change  of  place  and  scene  will  be  desirable.  The  mind  must  have 
entire  relaxation  by  easy  traveling  and  the  quiet  amusements  of  the  seaside. 
Foreign  watering  places  where  the  air  is  pure  and  the  waters  are  adapted  to 
promote  the  digestive  functions,  will  amply  compensate  for  a  long  visit. 

It  is  in  such  cases  as  these,  and  especially  in  nervous  and  irritable  subjects, 
that  the  bromides  of  potassium  and  ammonium  are  of  such  signal  value.  If 
the  patient  is  sleepless  at  night,  the  bromide  of  potassium  will  be  of  great 
service  if  taken  just  before  going  to  bed  (Form.  40);  and  if  he  is  unsteady 
on  rising  in  the  morning,  and  dreads  the  fatigue  and  business  of  the  day 
that  is  before  him,  the  bromide  of  ammonium  (Form.  25)  will  avert  the 
headache  which  threatens  with  the  toorning  light,  and  steady  his  nervous 
system  in  a  remarkable  way.  In  the  case  of  a  gentleman  who  suffers  period- 
ically from  a  subacute  congestive  headache,  and  who  is  also  troubled  at  these 
times  with  flatulent  dyspepsia,  a  full  dose  of  the  subcarbonate  of  bismuth  in 
plain  water  twice  a  day,  before  the  two  chief  meals,  always  controls  the 
headache  and  general  discomfort  and  flushing  of  the  face  (Form.  107). 

When  tonics  are  required  bark  and  ammonia,  or  ammonia  and  lavender, 
maybe  first  ventured  on  (Form.  55-62),  and  in  some  cases  they  answer  well. 
The  mild  preparations  of  iron  are  suitable  if  the  patient  is  weak  and  anemic 
(Form.  22-24),  but  they  must  be  cautiously  given  in  the  intervals  between 
the  attacks,  and  the  functions  of  digestion  and  assimilation  should  always 
claim  a  large  share  of  attention  during  their  administration. 


CHAPTER  VI. 

HEADACHE    FROM    PLETHORA   AND    INCREASED    VASCULAR    ACTION. 

Characters  and  Composition  of  the  Blood  in  Plethoric  States  of  the  Constitution — Predispos- 
ing and  Exciting  Causes — Variability  of  the  Symptoms  according  as  the  Disorder  is  of  a 
Sthenic  or  Asthenic  Type — Prevalence  of  the  Headache  at  the  Catamenial  Periods  and 
during  Pregnancy. 

Treatment — Natural  Cure  by  Spontaneous  Hsemorrhage  from  the  Bowels,  Nose  or  Uterus — 
Occasional  Necessity  for  Venesection  and  Cupping  or  Leeching  in  Active  Plethora — 
Saline  Aperients  to  Excite  the  Eliminative  Organs — Importance  of  Abstemious  Habits  and 
a  Limited  Indulgence  in  Animal  Food — Fish  and  Vegetables,  and  the  Influence  of  Diet 
on  the  Composition  of  the  Blood. 

In  this  variety  of  headache  there  is  an  excess  of  blood  in  the  whole  sys- 
tem, and  throughout  every  organ  of  the  body.  It  is  allied  to  the  congestive 
form ;  but  here  there  is  an  increased  quantity  of  blood  in  the  brain,  without 
any  corresponding  repletion  of  the  rest  of  the  vessels  of  the  body.  The  con- 
dition is  essentially  dependent  on  the  cerebral  vessels  partaking  of  the  gen- 
eral fulness,  and  is  not  due  to  the  determination  of  blood  towards  the  head 
in  particular.  The  redundancy  of  blood  in  the  brain  excites  morbid  action 
of  the  nerves  and  causes  headache,  whilst  the  general  plethoric  state  leads  to 
indolence  and  insufficient  exercise ;  and  with  defective  action  of  the  skin, 
liver,  and  bowels,  the  fulness  of  the  vessels  is  continually  kept  up.  When 
the  capillaries  are  too  full  they  favor  congestion,  by  the  exudation  of  their 
contents  through  their  thin  membranous  walls.* 

The  predisposing  causes  are  overindulgence  of  every  kind,  stimulating 
foods  and  drinks,  want  of  regular  exercise,  and  mental  lethargy.  Among 
the  exciting  causes  may  be  enumerated  any  circumstances  that  determine 
blood  to  the  brain  and  internal  organs.  The  suppressson  of  any  accustomed 
discharge,  as  epistaxis  or  hsemorrhoids,  will  induce  it.  I  knew  a  lady,  forty 
years  of^age,  short,  stout,  and  of  full  florid  habit,  who  only  obtained 
relief  from  violent  throbbing  headache  by  a  great  uterine  loss,  or  profuse 
bleeding  from  the  nose,  till  she  was  blanched  and  faint.  On  more  than  one 
occasion  she  was  on  the  verge  of  apoplexy,  when  the  haemorrhage  which  re- 
lieved her  came  on.f  There  had  been  for  some  days  previously  singing  in 
the  ears,  and  a  throbbing  and  bursting  sensation  in  the  head.  Purging  and 
low  diet  kept  the  symptoms  in  abeyance,  but  never  brought  so  much  relief 
as  this  unloading  of  the  general  circulation. 

A  fit  of  passion  in  a  sanguine  person,  or  exposure  to  the  heat  of  the  sun,  or 

*  It  is  important  to  remember  that  the  blood  in  plethora  is  different  in  its  composition  from 
what  it  is  even  in  active  hyperjemia.  With  the  increase  in  the  general  mass,  there  is  also  a 
larger  number  of  red  corpuscles  and  fibrin.  According  to  Dr.  Payne,  however,  the  fibrin  is 
somewhat  dimished  from  arterialization  (Jones  &  Sieveking's  Pathological  Anatomy,  page 
42).  The  quantity  of  water  is  very  considerably  less,  so  that  after  venesection  the  coagulum 
is  large,  and  the  serum  scanty.  In  the  asthenic  form  of  plethora  the  coagulum  is  softer,  be- 
cause the  tendency  to  an  approximation  of  the  red  particles  is  decreased,  and  they  are  more 
easily  drawn  asunder,  by  the  loss  of  attractive  force,  and  the  want  of  cohesion  between  the 
solid  and  fluid  parts. 

f  "  Plethoric  persons  are  not  more  prone  to  inflammation  than  are  those  of  weaker  consti- 
tution ;  but  they  are  liable  to  congestion,  especially  of  the  brain,  and  to  apoplexy  or  other 
haemorrhage." — Carpenter' s  Human  Physiology,  by  Power,  8th  edition,  p.  264. 

(61) 


62  HEADACHES. 

overcrowded  rooms  and  public  assemblies,  will  excite  this  headache,  if  there 
be  a  predisposition  to  it. 

Persons  who  suffer  from  this  sort  of  headache  look  well  and  strong;  they 
are  usually  stout  and  of  short  stature,  and  any  exertion  from  which  they  are 
instinctively  averse,  causes  a  throbbing  of  the  temples  and  a  rush  of  blood  to 
the  head. 

The  symptoms  vary  in  different  individuals.  In  the  more  sthenic  forms 
of  plethora  the  pulse  is  full  and  strong,  the  eyes  are  bloated  and  suffused, 
and  the  countenance  is  flushed  and  hot ;  the  veins  about  the  temple  and 
forehead  are  distended,  and  the  patient  experiences  so  much  discomfort  and 
confusion  in  his  head  on  any  attempt  at  movement,  that  he  encourages  his 
complaint  from  a  disinclination  to  exert  himself.  In  other  persons,  where 
there  is  less  arterial  excitement,  and  the  symptoms  approach  an  asthentic 
type,  the  pulse  is  small  and  hard;  and  in  some  it  is  weak  and  scarcely  dis- 
cernible or  intermittent,  as  when  the  heart  is  flabby  and  weak,  or  there  is  a 
tendency  to  the  deposition  of  fat  around  the  heart  and  in  the  subcutaneous 
areolar  tissue.  The  right  ventricle  is  habitually  too  full,  and  the  chief  veins 
of  the  neck  are  large  and  prominent.  Dyspnoea  on  exertion,  and  a  stifling 
cough  with  pulmonary  congestion,  are  also  common  in  these  subjects.  I 
have  met  with  persons  of  this  constitution  who  pass  urine  at  one  time  of  low 
specific  gravity,  sometimes  excessive,  and  at  others  containing  a  copious  de- 
posit of  pink  lithates  and  cayenne  pepper  crystals  of  uric  acid.  They  eat 
and  drink  immoderately,  and  fall  into  a  heavy  sleep  after  meals.  The  bow- 
els are  not  always  costive,  but  sometimes  loose  and  relaxed,  and  continue  so 
without  any  diminution  of  headache.  In  some  persons  the  extremities  are 
cold,  and  the  face  has  a  more  dusky  hue,  from  the  plethora  being  of  a  less 
active  character.  The  headache  is  heavy  and  throbbing,  chiefly  across  the 
forehead  or  the  occiput,  where  the  blood  accumulates  in  the  occipital  lobes. 
This  form  of  headache  may  precede  congestion  of  the  brain,  or  even  effusion 
and  apoplexy,  for  the  whole  capillary  system  is  too  full.  In  milder  cases 
there  is  dizziness  and  confusion  of  ideas,  with  a  mist  before  the  eyes ;  and 
any  excitement  or  exertion  causes  a  rush  of  blood  to  the  head,  and  heaviness 
of  breathing,  with  oppression  about  the  praecordia,  or  labored  action  of  the 
heart.  If  a  smart  attack  of  diarrhoea  supervene,  the  pain  is  partially  re- 
lieved ;  but  free  hccmorrhage  from  the  nose  or  bowels  will  cause  it  to  depart, 
even  after  a  steady  continuance  of  some  weeks. 

These  headaches  are  common  in  women,  and  are  severe  at  the  catamenial 
periods,  when  the  secretion  is  suppressed,  or  during  pregnancy ;  they  are  not 
always  persistent,  but  occasional,  and  are  excited  by  irritability  of  the 
digestive  organs  and  deficiency  in  the  powers  of  assimilation.  When  the 
latter  condition  exists,  the  fulness  of  habit  is  not  so  marked,  and  the  venous 
system  is  not  so  loaded;  the  circulation  is  more  active,  and  the  arteries  are 
less  disposed  to  relaxation,  while  the  blood  accumulates  in  the  capillary 
vessels. 

Treatment. — Nature  endeavors  to  promote  a  cure  by  the  occurrence  of 
haemorrhage  from  the  bowels,  nose,  or  uterus,  and  we  must  act  upon  this 
hint  if  we  would  effectually  relieve  the  headache.  I  knew  a  young  man 
residing  in  the  country  who  was  periodically  bled,  and  in  this  way  the  strain 
was  taken  off  the  cerebral  circulation,  and  his  symptoms  relieved.  Some 
years  ago  I  met  with  a  stout  plethoric  female,  twenty-five  years  of  age,  who 
was  about  to  give  up  her  situation  from  this  form  of  headache.  There  was 
a  full  hard  pulse,  and  scarcely  any  menstrual  flow,  till  a  free  bloodletting 
reduced  the  arterial  tension  and  restored  the  functions  of  the  sluggish  organs. 
But  there  are  many  persons  (particularly  women)  who  could  not  bear  vene- 


HEADACHE    FROM    PLETHORA   AND    INCREASED   VASCULAR   ACTION.       63 

section,  and  who,  nevertheless,  are  only  relieved  by  the  loss  of  blood  from 
the  nose  or  uterus.  These  belong  to  the  luxurious  classes,  and  the  brain  is 
as  much  in  a  state  of  passive  as  of  active  plethora;  it  is  the  accompaniment 
of  other  forms  of  headache,  and  must  not  be  sought  for  alone  and  unmixed 
in  all  cases.  Where,  then,  general  bleeding  is  inadmissible,  cupping  at  the 
back  of  the  neck,  or  a  few  leeches  to  the  anus  and  peringeum,  may  be 
resorted  to.  Saline  aperients  and  those  remedies  that  determine  the  force  of 
the  circulation  to  the  eliminative  organs,  must  also  be  employed  (Form.  18 
-19-60-80).  No  relief  can  be  obtained  unless  stimulating  food  and  intoxi- 
cating drinks  are  given  up,  and  the  sufferers  resolve  to  change  their  habits 
of  life  by  early  rising  and  regular  exercise,  that  as  much  blood  as  possible 
may  be  diverted  from  the  internal  organs,  and  pulmonary  and  cutaneous 
exhalation  encouraged.  The  sufferer,  however  (who  is  usually  a  bon- 
vivant),  cannot  endure  much  depletion,  and  demands  vigilance  and  judg- 
ment in  prescribing  for  him.  Meat  should  be  taken  not  oftener  than  once 
a  day,  and  fish  and  vegetables  are  highly  to  be  commended.  Many  persons, 
from  peculiarity  of  constitution  and  temperament,  cannot  maintain  their 
health  for  any  considerable  time  if  they  consume  animal  food  oftener  than 
once  a  day.  Diet  has  a  great  influence  on  the  composition  of  the  blood, 
and  we  may  so  regulate  it  as  to  diminish  the  tendency  to  the  formation  of 
solid  matter,  and  to  increase  the  watery  constituents.  Many  persons  are 
stronger  and  more  elastic  when  the  consumption  of  azotized  food  is  small ; 
and  in  cases  of  this  class,  there  is  no  probability  of  cure  unless  they  are 
willing  to  submit  to  a  careful  regimen.  Plethoric  persons  make  blood 
abudantly  from  an  innate  disposition  in  the  system  to  corpuscular  growth, 
and  sedentary  habits  and  high  living  will  encourage  the  predisposition. 

The  patient  should  lie  on  a  hard  bed  with  an  elevated  pillow,  as  the  re- 
cumbent position  encourages  determination  of  blood  to  the  head  and  con- 
gestion of  the  vessels.  The  meals  should  be  light,  that  sleep  may  not  after- 
wards ensue.  Moderate  and  regular  exercise  should  be  taken  in  the  open  air, 
and  the  mind  kept  as  free  from  disturbance  as  possible.  "  The  hair  should 
be  kept  short.  It  has  been  observed  that  monks  who  neglect  shaving  their 
heads  after  having  once  habituated  themselves  to  do  so  suffer  severely  from 
headache."* 

*  Headaches:  their  Causes  and  Cure,  by  Henry  S.  Wright,  M.  D.,  Philadelphia,  Blakiston. 


CHAPTER  Vn. 

NERVOUS     HEADACHE. 

Common  to  all  Classes  of  Society,  but  more  particularly  to  persons  of  Nervous  Tempera- 
ment and  Delicate  Organization — Pathology'  of  the  AfTection — Probably  dependent  on 
Ansemia  and  some  peculiar  Change  in  the  Cerebral  Tissue — Nerve  Storms  and  supposed 
Influence  of  Miasmatic  Poisoning— Variation  in  the  Seat  of  Pain  and  Mode  of  Com- 
mencement and  Teraiination — Want  of  Sleep,  and  Disturbance  of  the  Mind — Disturb- 
ance of  Vision — Cases  of  Sir  C.  \'\Tieatstone  and  Sir  J.  Herschel — Distribution  and 
Functions  of  the  Vasomotor  Nerves — Cases  in  Illustration  of  Nen-ous  Headache — Hered- 
itary Tendencies — Peculiar  Combination  of  Mental  and  Psychological  Symptoms — Origin 
of  the  Pain  in  Nervous  Headache — Effects  of  Nervous  Headache  on  the  Moral  Disposi- 
tion— Falling  oft  of  the  Hair,  and  Pityriasis  of  the  Scalp — Xanthelasma  Palpebrarum — 
Importance  of  Rest  and  Quiet — Cold  to  the  Head  and  Warmth  to  the  Feet — Effects  of 
Quinine,  and  Aperient  and  Sedative  Zvledicine — Bromides  of  Potassium  and  Ammonium 
— Guarana — Value  of  Hypodermic  Injecdon,  and  Importance  of  Caution  in  employing  it 
— Ferruginous  Tonics,  and  Strychnine,  and  Cod-liver  Oil. 

This  variety  of  headache  is  not  confined  to  any  particular  class  of  society, 
but  it  is  of  most  frequent  occurrence  in  persons  of  nervous  temperament 
and  delicate  organization.  No  temperament  can,  however,  claim  exemption 
from  it,  and  no  habit  of  body  is  proof  against  it.  Throughout  a  long  life 
it  periodically  attacks  those  who  are  susceptible  to  it,  and  they  surrender 
themselves  to  the  irresistible  evil  without  comment  and  without  murmur. 
They  feel  it  approaching  as  a  certainty  from  which  there  is  no  escape,  and 
so  placidly  resign  themselves  to  its  torture.  It  is,  to  a  certain  extent,  the 
headache  of  ansemia,  and  yet  not  entirely  so,  because  many  persons  are  af- 
fected with  it  whose  blood  is  neither  diminished  nor  impoverished,  and 
whose  muscular  development  and  robust  appearance  indicate  the  soundest 
health.  Amongst  its  victims  it  selects  persons  of  high  culture  and  vivid 
imagination,  and  if  at  the  same  time  they  are  deprived  of  their  full  allow- 
ance of  sleep,  it  all  the  more  readily  seizes  upon  them.  When  the  brain  is 
highly  developed  and  the  physical  organization  delicate,  it  is  always  likely 
to  occur.  It  is  in  the  want  of  balance  between  the  mental  and  physical 
state  that  a  nervous  headache  originates ;  for  when  the  circulation  is  ener- 
getic, and  the  digestive  organs  are  in  sound  working  order,  the  mind  may 
be  exerted  to  the  utmost  without  the  risk  of  incurring  it. 

All  investigation  concerning  this  form  of  headache  inclines  toward  a  ner- 
vous origin — to  a  morbid  change  in  the  nervous  centres ;  and  this  view  can- 
not be  readily  dismissed  until  the  discoveries  of  experimental  physiology  are 
proved  to  be  inconclusive  or  erroneous.  It  is  infinitely  less  probable  that 
the  cerebral  blood-supply  should  initiate  the  disturbance,  whatever  share  it 
may  subsequently  have  in  producing  the  pain.  But  clothe  the  arguments  as 
we  may  to  support  this  or  that  opinion,  reproduce  them  as  we  will  to  the 
proof  of  conviction,  we  are  still  in  the  infancy  of  knowledge  concerning  the 
causes  of  many  diseased  processes,  and  the  evidence  which  now  appears  in- 
dubitable may  be  far  distant  from  ultimate  truth. 

Nervous  headache  comes  on  sometimes  Avhen  a  patient  dwells  persistently 
on  anything  unpleasant,  or  is  unable  to  remove  his  thoughts  from  it ;  when 
be  cannot  be  cheerful  in  repose,  or  see  the  faintest  sunshine  in  the  future. 
This  tries  the  brain,  and  disarranges  the  circulation  within  it ;  for  "  the  fact 

(64) 


NERVOUS    HEADACHE.  65 

is  now  generally  admitted  that  thought  exhausts  the  nervous  substance,  as 
surely  as  walking  exhausts  the  muscles.  Our  physical  framework  is  involved 
with  thought  no  less  decidedly  than  with  feeling,  and  it  is  requisite,  if  possi- 
ible,  to  define  the  terms  of  the  alliance."  * 

Persons  know  when  this  form  of  headache  is  threatening,  and  by  rest  and 
extreme  care  they  may  ward  it  off  altogether.  Thus  at  an  early  stage,  its 
full  force  may  be  averted  by  going  to  bed  and  falling  asleep ;  if  it  threatens 
before  the  accustomed  time  of  taking  food,  a  moderate  meal  will  prevent  it, 
or  a  full  dose  of  bromide  of  potassium.  Sometimes  the  routine  duty  of  the 
day  can  be  got  through,  and  the  misery  endured;  at  other  tnnes  the  pain 
reaches  such  a  degree  of  severity  that  there  is  no  standing  up  against  it,  and 
the  patient  is  compelled  to  give  in. 

This  peculiar  functional  disorder  of  the  nervous  centres  is  neither  perma- 
nent nor  continuous,  and  in  the  interval  of  the  seizures  the  patient  is  as  well 
as  though  it  had  not  happened.  This  disease  has  been  very  appropriately, 
I  think,  classed  among  the  paroxysmal  neuroses  by  Dr.  Hilton  Fagge,t  for 
it  comes  and  goes  suddenly,  often  when  least  expected,  and  without  warn- 
ing. But  this  is  the  character  of  nervous  disorders  generally,  as  facial  neu- 
ralgia, epilepsy,  laryngismus  stridulus,  gastrodynia,  angina  pectoris,  etc. 
Dr.  Edward  Liveingt  gives  them  the  name  of  "nerve  storms."  As  we 
shall  presently  see,  this  type  of  headache  is  among  the  most  hereditary  of 
diseases.  From  the  mode  and  habits  of  life,  when  the  nervous  system  has 
been  subjected  to  great  strain,  it  may  break  out  anew  in  a  single  member  of 
a  family,  when  no  other  member  of  it  suffers  from  any  neurotic  disorder. 
The  occupation  of  each  one's  life  exercises,  either  consciously  or  uncon- 
sciously, an  important  influence  on  the  bodily  and  mental  state,  and  each 
calling  may  have  a  large  share  in  determining  our  susceptibilities.  In  some 
persons  the  headache,  which  I  would  designate  as  strictly  nervous,  begins 
with  an  affection  of  vision,  the  sight  being  clouded  and  dim  on  that  side  of 
the  head  where  the  pain  commences  (as  in  one  temple),  afterwards  followed 
by  the  usual  phenomena  of  sickness  and  confusion  of  ideas,  independent  of 
any  excess  or  diminution  in  the  blood-supply.  It  is  traceable  in  some  cases 
to  exhaustion,  fatigue,  and  losses  of  blood  ;  but  more  commonly  to  worry 
and  anxiety;  in  others,  no  cause  can  be  assigned — it  comes  and  goes  with-  . 
out  any  satisfactory  reason,  and  lays  the  robust  and  square-shouldered  man 
as  prostrate  as  the  overdrained  sickly  woman.  In  employing  the  term 
"  nerve  storms,"  Dr.  Liveing  implies  that  there  is  an  accumulation  of  ner- 
vous force  which  explodes  in  the  shape  of  headache;  and  it  is  certain  that 
all  who  have  carefully  observed  the  phenomena  leading  up  to  an  attack  must 
have  been  struck  with  the  excitement  of  manner  and  irritability  which  pre- 

*Mind  and  Body,  by  Alexander  Bain,  L.L.  D.,  1873,  p.  80. 

f  Remarks  on  some  of  the  Paroxysmal  Neuroses,  Guy's  Hospital  Reports,  vol.  xxi., 
1876,  p.  376. 

J  "  On  this  theory,  then,  the  fundamental  cause  of  all  neuroses  is  to  be  found,  not  in  any 
irritation  of  the  viscercal  or  cutaneous  peripherj^,  nor  in  any  disorder  or  in-egularit}'  of  the 
circulation,  but  in  a  primary  and  often  hereditary  vice  or  morbid  disposition  of  the  nervous 
system  itself  This  consists  in  a  tendency  on  the  part  of  the  nervous  centres  to  the  irregular 
accumulation  and  discharge  of  nerve  force — to  disruptive  and  uncoordinated  action,  in  fact; 
and  the  concentration  of  this  tendency  in  particular  localities,  or  about  particular  foci,  will 
mainly  determine  the  neurosis  in  question.  The  immediate  antecedent  of  an  attack  is  a 
condition  of  unstable  equilibrium  and  gradually  accumulating  tension  in  the  parts  of  the  ner- 
vous system  more  immediately  concerned,  while  the  paroxysm  itself  may  be  likened  to  a 
storm,  by  which  this  condition  is  depressed,  and  equlibrium  for  the  time  restored." — On 
Megrim  and  Sick  Headache,  1873,  V-  33^- 


^6  HEADACHES. 

cede  the  outbreak.  The  period  may  vary  from  a  few  hours  to  many  days. 
In  some  confirmed  suiferers  I  have  repeatedly  witnessed  a  series  of  symp- 
toms Avhich  have  cuhninated  in  an  attack,  and  no  ease  has  been  obtained  till 
the  affection  has  worked  up  to  its  height.  There  is  a  period  during  which 
disease  obtains  the  mastery,  and  all  remedies  are  unavailing  to  keep  it  in 
check.  If  the  general  health  is  reduced,  the  attacks  are  more  frequent, 
and  recur  with  no  precise  regularity ;  but  when  the  health  is  stronger,  the 
intervals  are  also  greater.  Worry  is  a  common  exciting  cause  in  both  men 
and  women,  especially  if  they  are  sensitive  and  given  up  to  society  and 
excitement.  A  mind  ill  at  ease  becomes  exalted  or  depressed,  and  the  cere- 
bral circulation  being  unsteady  deranges  the  nervous  structure.  Overwork 
of  the  brain  is  another  cause  in  those  persons  who  live  in  towns  and  large 
cities,  and  pursue  sedentary  occupations. 

When  the  paroxysms  recur  with  regularity,  miasmatic  poisoning  requires 
to  be  taken  into  consideration ;  but  I  must  say  that  this  cause  has  rarely  sug- 
gested itself  to  my  belief,  for  nervous  headache  is  more  common  to  residents 
in  large  and  populous  towns,  where  marsh  poison  does  not  prevail,  whilst  it 
is  questionable  whether  the  disease  is  especially  frequent  in  aguish  districts. 
When  a  nervous  headache,  having  all  the  characters  of  true  migraine,  follows 
certain  articles  of  diet,  as  pork,  butter,  fatty  articles  of  food,  and  alcohol,  it 
is  beyond  doubt  that  these  have  had  a  large  share  in  provoking  the  mischief. 
We  are  repeatedly  told  by  patients  that,  unless  they  observe  the  greatest 
care,  they  will  suffer  the  penalty  of  a  headache  for  indiscretion. 

The  pain  most  usually  attacks  the  forehead  and  vertex,  but  sometimes  the 
occiput  and  back  of  the  neck.  After  it  has  lasted  some  time,  it  not  unfre- 
quently  seizes  upon  one  temple,  or  one  eye,  or  one-half  of  the  head,  and 
thus  resembles  the  headache  of  neuralgia.  A  married  lady,  set.  30,  consult- 
ed me  in  May,  1876,  for  a  nervous  headache,  to  which  she  had  long  been 
subject.  It  began  over  the  forehead,  and  in  the  course  of  an  hour  or  two 
would  seize  on  the  left  eye,  where  it  would  continue  for  a  whole  day,  and 
then  leave  her  after  a  night's  rest.  The  feeling  she  described  to  be  as 
though  something  was  forcing  out  the  left  eye,  the  tears  running  over  the 
cheek  so  plentifully  that  it  became  inflamed  and  sore,  while  the  pain  ex- 
tended down  the  left  side  of  the  nose;  also  light  and  sound  became  intoler- 
able to  her.  The  patient  stated  that  through  life  she  had  been  subject  at 
times  to  '■^ bilious  attacks,'"  and,  though  still  she  often  would  feel  nausea, 
she  never  actually  vomited.  With  this  condition  of  the  brain  the  hands  and 
feet  were  always  cold,  and,  if  the  pain  had  continued  long,  the  head  grew 
hot,  as  if  full  of  blood,  and  the  face  became  flushed.  However  severe  the 
suffering,  she  could  always  eat  her  dinner,  which  sometimes  relieved  the 
pain,  and  at  other  times  increased  it.  When  the  pain  was  coming  on,  she 
told  me  that  she  was  always  inclined  to  cry  at  the  slightest  thing. 

The  approach  of  headache  in  some  persons  may  be  foretold  by  the  sluggish 
action  of  the  bowels,  a  loathing  of  food,  together  with  flatulency  and  eructa- 
tion. In  the  same  class  of  persons,  at  other  times,  I  have  known  a  state  of 
chilliness  and  a  very  scanty  and  turbid  secretion  of  urine  to  precede  the 
headache ;  while  with  other  persons,  the  passing  of  a  large  quantity  of  limpid 
urine  maybe  the  forerunner  of  an  attack.  In  others,  again,  there  is  extreme 
irritability  and  disquietude ;  the  patient  cannot  keep  quiet  for  an  instant, 
and  no  efforts  avail  to  calm  or  appease  her ;  all  things  are  wrong — nothing 
goes  right.  The  pupils  are  contracted,  the  eyes  sunken,  the  pulse  feeble, 
and  the  extremities  cold.  Then  succeeds  a  period  of  calm  and  surrender, 
and  the  patient  is  completely  exhausted  and  overcome.  This  headache  is 
most  frequent  among  women  who  are  approaching  the  middle  period  of  life, 


NERVOUS    HEADACHE.  6/ 

and  who  are  exhausted  by  the  strain  of  maternal  duties.  If  they  have  borne 
children  rapidly,  and  the  uterine  functions  are  active,  then  it  is  of  common 
occurrence.  Oversuckling,  menorrhagia,  and  profuse  leucorrhoea  are  also 
causes;  dysmenorrhcfea,  and  even  ordinary  menstruation,  will  bring  it  on  in 
some  persons.  As  regards  menstruation  as  an  exciting  cause,  the  quantity 
of  loss  affords  no  explanation,  for  nervous  headache  is  as  common  where  the 
catamenia  are  deficient,  as  where  they  are  in  excess.  The  ovarian  irritation 
which  prevails  at  these  periods,  induces  a  painful  condition  of  the  cerebral 
nerves  through  sympathetic  action ;  and  there  are  women  who  invariably 
suffer  in  this  way  at  every  menstrual  period,  when  the  quantity  of  loss  can- 
not explain  the  occurrence  of  the  pain.  The  real  disorder  is  in  the  nerve- 
fibres  of  the  brain,  which  become  deranged  from  distant  sources  of  irritation 
acting  through  the  sympathetic  system.* 

Constipation  is  sometimes  held  to  be  a  cause  of  nervous  headache,  when, 
in  reality,  it  is  an  effect.  If,  when  the  attack  comes  on,  the  bowels  happen 
to  be  costive,  the  pain  in  the  head  is  increased  from  the  greater  sympathetic 
action  ;  but  if  they  happen  to  be  relaxed,  the  pain  is  the  same,  and  mere 
looseness  of  the  bowels  does  not  relieve  it.  Those  who  are  subject  to  this 
form  of  headache,  although  they  may  have  escaped  it  for  many  years  of  their 
life,  are  persons  whose  constitution  is  originally  weak.  I  have  known  per- 
sons to  reach  the  age  of  thirty-five  before  getting  an  attack,  and  then,  cir- 
cumstances having  arisen  to  lower  the  standard  of  health,  the  consequent 
excessive  waste  of  nervous  matter  has  rendered  them  liable  to  the  complaint. 
The  hard-worked  physician,  the  laborious  scholar,  the  anxious  merchant, 
who  toil  hard  and  late,  and  neglect  the  ordinary  precautions  of  health ;  the 
corrupted  youth,  who  has  sacrificed  himself  to  vicious  habits ;  the  ansemic 
girl,  and  the  half-starved  seamstress- — all  are  victims  of  this  terrible  form  of 
headache.  Those  who  dwell  in  the  fashionable  world,  and  keep  late  hours, 
are  particularly  subject  to  it ;  for  hot  rooms,  evening  parties,  and  imperfect 
ventilation  are  always  likely  to  produce  it. 

But,  in  addition  to  the  activity  of  the  mind  and  the  emotional  sensibility 
which  are  common  to  the  sufferers  of  nervous  headache,  there  is  a  state  of 
the  bodily  constitution  which  renders  people  liable  to  it.  In  a  lowered  con- 
dition of  the  general  health  almost  any  cause  will  induce  an  attack.  Pro- 
longed study,  the  mind  being  kept  bent  on  the  accomplishment  of  a  task  in 
a  given  time,  pondering  over  figures  that  require  much  mathematical  calcu- 
lation, the  jarring  of  vehicles  over  bad  roads,  the  alarm  and  timidity  at  driv- 
ing along  crowded  thoroughfares,  and  disagreeable  odors  of  all  kinds,  will 
be  sufficient  to  invite  it  in  some  cases.  All  forms  of  peripheral  irritation  of 
the  senses  of  sight  and  hearing  excite  increased  central  irritation,  especially 
in  cases  of  meningeal  mischief;  consequently  we  find  that  darkened  rooms 
and  absolute  silence  are  excellent  palliative  measures.  Moreover,  depraved 
secretions  in  the  alimentary  canal,  or  any  morbid  impression  on  the  gastric 
nerves,  will  bring  it  on. 

Difficult  as  it  is  to  fix  upon  exciting  causes,  we  can  hardly  escape  the  con- 
viction that  derangement  in  the  chylopoietic  viscera  has  an  important  bear- 
ing in  the  causation  of  the  malady.  The  interruption  to  the  process  of 
digestion  caused  by  traveling  on  a  full  stomach  invariably  brings  on  a  head- 
ache with  some  persons.  I  have  met  with  several  cases,  and  one  in  particular, 
where  a  gentleman  alwa3^s  suffers  from  headache  if  he  goes  a  journey  shortly 
after  taking  food.  There  are  persons  of  similar  nervous  organization,  who 
experience  a  sharp  attack  of  diarrhoea  at  the  prospect  of  traveling  by  rail, 
or  going  a  sea  voyage. 

*See  Cliapter  III.,  on  Sympathetic  Headaclie. 


68  HEADACHES. 

Disturbance  in  the  electrical  states  of  the  atmosphere  will  excite  an  attack 
of  nervous  headache  in  some  persons.  By  these  persons  the  approach  of  a 
thunderstorm  can  be  calculated  with  an  absolute  certainty  from  the  feeling 
of  weight  over  the  forehead  and  a  severe  headache.  '  Long  before  thunder 
is  heard,  or  the  patient  has  any  conception  that  a  storm  is  coming  on,  he  is 
heavy  and  oppressed,  or  restless  and  timid ;  there  is  a  weight  across  the 
forehead,  and  he  is  unable  to  exert  himself  in  mind  or  body.  If  he  attempts 
to  read,  his  temples  beat  and  his  forehead  aches,  his  face  flushes,  and  his 
last  meal  has  probably  caused  flatulence,  and  a  sense  of  heat  and  dryness  in 
the  mouth.  Abstinence  from  food  and  continuous  effort  may  keep  the  pain 
in  abeyance,  but  still  it  clings  to  him  more  or  less,  and  he  gets  through  the 
day's  work  miserably  enough. 

As  regards  disturbances  of  vision,  all  the  patients  who  have  complained  to 
me  of  this  symptom  have  described  a  painful  sensation  on  attempting  to 
read  or  look  at  objects,  and  a  misty  or  clouded  appearance  before  the  eyes, 
or  flashes  of  light  and  dazzling  sparks  in  the  field  of  vision.  One  female 
patient  assured  me  that  a  dim  and  clouded  appearance  before  the  left  eye 
announced  the  commencement  of  the  attack  for  some  hours  before  the  head 
began'  to  ache.  Sir  C.  Wheatstone,  Sir  John  Herschel,  and  other  eminent 
men,  describe  their  own  experience  of  it,  and  for  another  interesting  account 
I  would  refer  to  the  Philosophical  Transactions  for  1870,  "  On  a  Distinct 
Form  of  Transient  Hemiopsia,"  by  Dr.  Airy.  Sir  J-  Herschel  describes  a 
singular  shadowy  appearance  at  the  outside  corner  of  the  field  of  vision  in 
the  left  eye,  coming  on  when  he  was  doing  nothing  and  thinking  of  nothing. 
It  gradually  assumed  the  drawing  of  a  fortification,  with  angles,  bastions, 
and  ravelins,  and  faint  lines  of  color  between  the  dark  lines,  and  the  im- 
pression was  the  same  whether  the  eyes  were  closed  or  open.  It  lasted  a 
minute  or  two,  and  spread  over  the  whole  visual  area,  and  was  not  followed 
by  headache  as  it  was  in  another  case.  The  account  given  by  Dr.  Airy  of 
the  phenomena  is  very  interesting,  and  will  repay  careful  consideration. 
"Another  very  important  point  about  these  attacks  is,  that  in  perhaps  from 
one-fourth  to  one-third  of  the  cases,  during  this  glimmering  stage,  there  is 
tingling  in  some  portion  of  the  body — the  part  is  asleep.  In  a  young  female 
that  I  saw,  the  tingling  affected  one  arm  and  the  side  of  the  tongue,  and, 
curiously  enough,  both  her  sister  and  her  father  were  affected  in  precisely 
the  same  way.  The  tingling  was  on  the  same  side  as  that  on  which  the 
glimmering  in  the  eye  began.  In  another  case,  the  patient  complained  of  a 
feeling  of  pricking  and  scratching  on  that  side  of  the  face  corresponding 
with  the  glimmering.  In  others,  speech  or  hearing  may  be  aff'ected.  "^ 
The  persons  who  suffer  from  ocular  disturbance  are,  in  my  experience,  most 
frequently  women  of  nervous  temperament,  who  have  active  brains,  and  are 
energetic  and  restless.  They  are  often  ansemic  and  subject  to  chronic 
debility.  Fatigue  of  all  kinds  and  overexcitement  will  lead  to  it,  and  all 
drains,  leucorrhoea  or  menorrhagia,  which  exhaust  the  system  and  lower  the 
bodily  tone,  are  common  causes.  Under  "  Sympathetic  Headache  "  I  have 
described  how  this  state  is  brought  about,  and  I  may  here  mention  that  the 
vasomotor  branches  of  the  sympathetic  nerve  regulate  the  contraction  and 
dilatation  of  the  bloodvessels  of  the  brain ;  and  we  have  seen  that  when  the 
cervical  sympathetic  was  divided,  there  was  an  afflux  of  blood  and  a 
dilatation  of  the  vessels.  When  the  vessels  of  the  brain  are  contracted,  the 
supply  of  blood  is  diminished  ;  when  they  are  dilated  the  quantity  is  in- 
creased j  and  this  is  an  explanation  of  the  headache  that  results  after  the 

*Dr.  Latham,  on  Nervous  or  Sick  Headache,  p.  10. 


NERVOUS    HEADACHE.  69 

Stage  of  excitement  has  passed,  when  the  systemic  circulation  is  heightened 
and  increased.* 

The  following  case  is  one  carefully  studied,  and  may  be  regarded  as  a 
type  of  nervous  headache.  Each  attack  seemed  to  divide  itself  into  two 
distinct  periods— ^rst,  the  stage  of  irritation,  where  the  brain  is  first  at  fault, 
and  the  stomach  secondarily  affected;  secondly,  the  neuralgic  stage.  This 
will  be  best  explained  by  the  sufferer's  own  account,  as  communicated  to  me 
from  time  to  time  : 

A.  B.,  aet.  49,  began  to  suffer  from  severe  headache  twelve  years  ago, 
being  then  the  mother  of  four  children  which  she  had  had  in  rapid  succession, 
besides  two  premature  births,  all  in  the  course  of  seven  years.  After  this 
she  had  great  and  frequent  catamenial  losses,  which  compelled  her  to  keep 
her  bed  or  to  remain  in  a  recumbent  posture  for  days  together.  The  head- 
aches generally  came  on  the  third  day  of  the  loss,  though  occasionally  at 
other  times,  and  then  they  were  always  traceable  to  fatigue  or  worry.  At 
the  onset  of  each  attack  she  complained  of  violent  pain  on  the  top  of  her 
head  (which  was  always  very  hot),  extending  over  the  occiput  to  the  neck. 
The  eyes  were  sunken  in  the  orbits,  and  the  pupils  were  small  and  con- 
tracted, and  there  was  a  feeling  as  though  they  were  being  pulled  back  into 
the  head;  light  and  sound  were  intolerable;  the  feet  and  hands  cold;  the 
pulse  slow  and  feeble,  sometimes  not  exceeding  fifty  beats  in  a  minute.  The 
bowels  refused  to  respond  to  medicine.  Sometimes  she  obtained  partial 
relief  from  ice  on  her  head,  while  at  other  times  she  could  not  lie  still,  but 
kept  pacing  up  and  down  the  room,  with  her  mind  much  disquieted,  and  a 
wish  to  die.  When  the  suffering  was  acute,  the  patient  could  not  rest  her 
head  on  the  pillow,  nor  could  she  open  her  eyes  or  engage  in  conversation. 
She  was  continually  tossing  and  turning  from  one  position  to  another,  while 
her  mind  indulged  in  the  most  melancholy  forebodings,  and  renewed  the 
fancied  grievances  of  a  lifetime.  She  could  not  escape  from  the  toils  of 
calculation ;  her  mind  kept  running  in  a  narrow  groove,  and  all  things  ap- 
peared distorted.  This  stage  would  last  as  long  as  thirty-six  hours,  being 
sometimes  accompanied  by  sickness,  and  sometimes  not;  but  no  food  could 
be  borne,  and  her  sleep,  which  was  broken,  seldom  brought  any  relief,  for 
she  continually  awoke  groaning  with  pain.  Very  gradually,  however,  a 
change  in  the  character  of  the  headache  invariably  ensued;  acute  neuralgic 
pain,  coming  and  going  over  one  or  both  brows,  would  set  in,  and  occupy 
the  place  of  the  other,  which  now  slowly  decreased.  From  this  moment  she 
was  able  to  take  plenty  of  soup,  champagne,  and  quinine. 

This  case  baffled  all  attempts  at  relief  till  the  hypodermic  injection  of 

*"That  tliere  is  a  vasomotor  centre,  and  tliat  it  is  intracranial,  we  learn  by  observing, 
first,  that  if  the  medulla  is  divided  immediately  below  the  cerebellum,  all  the  arteries  are 
relaxed,  and  that  a  similar  effect  is  produced  if  certain  afferent  nerve-fibres  which  lead  to  the 
intracranial  part  of  the  cord  are  excited.  Its  position  has  been  lately  determined  with  great 
precision  in  the  rabbit  by  Ludwig  and  Owsjannikow,  who  have  found  by  experiments  that 
it  is  limited  towards  the  spinal  cord  by  a  line  four  or  five  millimeters  above  the  calamus 
scripto7-ms,  and  extends  towards  the  brain  to  within  a  millimeter  of  the  corpora  qiiadrige- 
mina. 

"  That  the  vasomotor  centre  is  in  constant  automatic  action  is  shown  by  the  paralyzing 
effect  of  section,  whether  of  the  spinal  cord,  or  of  any  nerve  known  to  contain  vascular 
fibres.  If  the  action  of  the  centi'e  were  not  constant,  division  could  not  produce  arterial  re- 
laxation. In  relation  to  this  constancy  of  action,  the  word  lomcs  is  used.  Arterial  tonus 
means  that  degree  of  contraction  of  an  artery  which  is  constant  and  normal.  It  is  main- 
tained only  so  long  as  the  artery  is  in  communication  with  the  vasomotor  centre." — Hand- 
book for  the  Physiological  Laboratory,  "  Functions  of  Vasomotor  Nerves,"  by  Dr.  Burdon- 
Sanderson,  Philadelphia,  Blakiston. 


70  HEADACHES. 

morphia  was  tried  ;  and  then,  after  days  of  maddening  pain,  the  patient 
would  turn  aound  at  once  and  sleep  tranquilly  for  twenty-four  hours.  She 
awoke  with  the  neuralgic  period  to  ensue,  but  fortified  to  bear  it,  and  after 
a  few  days'  weakness  and  exhaustion,  during  which  the  eye  retained  the 
drawn-back  feeling,  she  regained  her  usual  health. 

Note. — February,  1877.  During  the  last  six  months  the  patient  has  suf- 
fered less  from  the  variety  of  headache  she  formerly  complained  of,  but  her 
general  health  has  sensibly  declined,  and  she  is  fatigued  after  the  slightest 
mental  or  physical  exertion  ;  the  noise  of  the  street,  the  sound  of  music,  or 
the  excitement  of  ordinary  conversation,  are  all  too  much  for  her,  and  she 
has  the  manner  and  appearance  of  a  confirmed  invalid.  Her  blood  shows 
indications  of  great  impoverishment  and  anaemia,  as  evidenced  by  an  irrita- 
ble and  red  eruption  on  the  nose  and  face,  troublesome  pityriasis  of  the  scalp, 
and  purple  patches  of  ecchymosis  at  the  inner  angles  of  the  upper  eyelids, 
which  are  always  increased  during  and  just  after  a  seizure  of  headache.  When 
the  eruption  began  to  subside  she  complained  of  pain  in  and  about  her  eyes, 
of  a  very  distressing  character;  she  could  not  bear  the  light,  and  to  move  the 
eyes  (especially  the  left),  either  outwards  or  inwards,  caused  acute  suffering. 
There  was  also  frequent  neuralgia  of  the  right  and  left  brow,  and  she  had 
great  difficulty  in  reading,  her  sight  seeming  to  go  for  a  time  when  she  made 
the  effort,  the  letters  appearing  clouded  and  misshapen.  The  light  was  so 
trying  to  the  e3'es  that  she  always  preferred  a  darkened  room,  and  when  able 
to  venture  out  of  doors  she  wore  blue  spectacles  with  advantage.  There 
was  no  optic  neuritis.  Six  months'  absence  from  home  life  and  staying  at 
different  quiet  places  where  the  air  was  pure,  and  getting  plenty  of  rest, 
restored  her  general  health  in  a  remarkable  manner,  and  enabled  her  diges- 
tive powers  to  assimilate  iron  and  arsenic  (Form.  24  /5)  and  a  glass  of  port 
wine  at  her  midday  meal.  She  was  also  able  to  take  brandy  and  egg  mix- 
ture, and  a  full  dose  of  quinine  when  an  attack  ofhemicrania  was  threatening. 
Bromide  of  potassium  at  night,  and  aconitina  ointment  (Form.  112-113), 
applied  over  the  brow,  often  cut  short  the  paroxysm,  and  procured  sleep. 
Moderate  exercise,  short  of  fatigue,  was  of  advantage,  but  the  least  worry  or 
anxiety  invariably  threw  her  back  for  several  days.  All  chance  of  success 
depended  upon  the  power  to  improve  the  quality  of  the  blood,  and  to  remove 
the  ansemia  of  the  tissues. 

Note. — October,  1877.  On  returning  to  home  duties,  severe  paroxysm 
came  on,  and  after  three  days  of  increasing  agony  and  confinement  to  bed 
without  a  monient's  respite  from  pain,  she  suddenly  became  collapsed  and 
pulseless,  with  cold  extremities,  and  her  condition  for  a  few  manutes  was 
very  alarming.  She  was  unable  to  swallow  for  some  time,  till  external 
warmth  and  friction  had  restored  her  faltering  circulation,  and  then  the 
effort  was  accomplished  with  the  greatest  difficulty,  owing  to  a  sense  of  suffo- 
cation which  the  attempt  excited.  From  this  time  "the  nerve  storm" 
abated  in  severity,  leaving  the  patient  very  prostrate,  but  free  from  pain. 

Note. — April,  1879.  Since  the  above  report  the  general  state  of  health 
has  improved,  but  the  headaches  have  assumed  a  more  neuralgic  type,  the 
pain  seizing  the  right  or  left  tem.ple,  or  both  temples,  and  finally  settling  into 
what  she  describes  as  "back  of  the  eyeballs."  It  is  of  so  severe  a  character 
that  she  cannot  bear  the  light,  or  even  lie  still  for  many  minutes  together. 
There  is  generally  coldness  of  the  extremities,  shivering,  pallor,  small  con- 
tracted pulse,  and  a  sense  of  indescribable  misery  and  exhaustion.  A  full 
dose  of  quinine  (five  grains,  with  a  few  drops  of  spirit  of  chloroform  and 
water),  followed  soon  afterwards  by  a  glass  of  champagne,  or  brandy  in  soda- 
water,  has  sometimes  been  found  to  shorten  the  attack,  if  given  early  enough; 


NERVOUS    HEADACHE.  7 1 

but  more  often  the  suffering  has  been  prolonged  over  two  days,  notwith- 
standing that  the  quinine  has  been  repeated  every  two  or  three  hours,  with 
various  kinds  of  nourishment  given  in  the  intervals.  The  pain  is  traceable 
to  indigestion,  worry  of  mind,  fatigue,  excitement,  and  cold  winds. 

C.  D.,  set.  40,  m. ;  three  children,  one  miscarriage,  active  and  energetic 
temperament.  When  she  first  consulted  me  in  November,  1874,  she  had 
been  complaining  of  headaches  for  five  months  previously.  Any  exertion 
would  bring  these  headaches  on,  and  they  generally  came  either  after  or  dur- 
ing the  flow  of  the  catamenia;  especially  if  she  took  extra  exertion,  or  was 
in  any  way  excited.  The  patient  had  suffered  from  neuralgia  of  the  face 
for  many  years,  but  these  attacks  seldom  recurred  now.  When  these  head- 
aches were  coming  on,  small  things  would  worry  and  annoy  her  ;  she  could 
not  sleep,  but  would  light  a  candle  and  read.  They  did  not  come  on  sud- 
denly, but  the  patient  was  aware  of  their  approach,  and  could  ward  them  off 
altogether  by  rest  and  quiet.  The  bowels  were  always  inclined  to  act  too 
freely,  and  before  marriage  there  had  been  great  dysmenorrhoea.  First,  a 
general  sense  of  discomfort  and  confusion  in  the  head  was  felt,  trifles  assum- 
ing undue  importance,  one  idea  running  persistently  in  her  head,  while  the 
patient  lost  all  sense  of  proportion.*  If  the  pain  increased,  it  became 
localized  in  the  temples  and  the  top  of  the  head,  and  there  was  a  feeling  as 
if  something  were  being  driven  into  them.  "  It  seems,  however,"  said  the 
patient,  "as  if  my  spine  must  be  in  some  degree  affected,  for  I  am  obliged 
to  lie  with  my  chin  raised,  so  as  to  rest  the  back  of  my  neck."  The  intense 
pain  varied  considerably  in  duration — from  about  six  hours  to  twenty-four. 
When  the  headaches  abated,  sleep  generally  ensued  for  a  considerable  num- 
ber of  hours;  and,  on  waking,  the  pain  was  gone,  though  the  head  was  sore 
and  weak.  If  the  attack  Avas  very  acute,  five  or  six  days  would  elapse  before 
she  recovered  her  usual  strength.  Formerly,  when  the  headaches  were  very 
severe,  she  had  slept  badly  for  six  months ;  now  she  had  quite  recovered  her 
sleep,  except  just  before  an  attack  of  headache.  The  patient  writes  (April, 
1876)  that  she  followed  medical  advice  for  six  months.  In  addition  to  the 
headache,  when  she  first  consulted  me,  there  was  great  uterine  loss  and  re- 
laxation of  the  bowels.  Both  these  functions  are  right  now,  but  if  she 
happens  to  get  a  return  of  the  one,  she  also  has  a  return  of  the  other.  The 
headaches  are  far  less  frequent  than  they  were  eighteen  months  ago,  and  as 
a  rule  much  less  severe.  At  the  time  of  consultation  (November,  1874),  the 
pulse  was  weak,  and  only  sixty  beats  per  minute;  the  tongue  was  clean,  the 
eyes  were  energetic,  but  her  looks  showed  exhaustion.  The  treatment  con- 
sisted in  all  possible  rest,  mental  and  physical,  particularly  at  the  menstrual 
periods.  A  preparation  of  iron  (Form.  39)  was  to  be  taken  twice  a  day 
after  food,  and  bromide  of  potassium  at  night  (Form.  40).  A  month  later 
all  the  symptoms  of  relaxation  had  improved,  and  bromide  of  ammonium 

*  All  states  of  nervous  exhaustion,  whether  brought  on  by  inordinate  indulgence  in  drink, 
or  by  the  ordinary  avocations  of  life,  are  capable  of  giving  rise  to  subjective  sensations  of 
the  strangest  character.  They  may  be  described  as  hallucinations — phantoms  of  the  unreal 
and  imaginary.  I  have  met  with  some  sufferers  from  headache  who,  in  their  suspended 
moments  of  agony,  have  told  me  that  they  have  no  power  to  give  the  aching  brain  rest.  As 
the  pain  lulled,  the  functions  of  the  brain  became  unduly  active,  and  the  mind  busy  with 
the  miraculous ;  tortured  with  the  fear  of  death,  or  the  dread  of  committing  suicide.  Emo- 
tional excitement,  and  real  or  imaginary  wrongs,  will  take  possession  of  the  sufferer,  and  he 
can  no  more  command  himself  and  shake  off  the  supernatural  belief,  than  he  can  bid  the 
throbbing  brain  be  still.  This  is  the  outcome  partly  of  a  disturbed  circulation,  causing,  it 
may  be,  some  arrest  or  interference  with  the  passage  of  the  blood  through  the  vessels  which 
supply  the  brain  and  nourish  its  delicate  tissue,  and  still  more  of  an  irritable  and  exhausted 
state  of  the  cerebral  cells.     Irritability  is  the  forerunner  of  exhaustion  in  nerve-matter. 


72 


HEADACHES. 


was  substituted  for  the  previous  medicines  (Form.  25).  At  the  close  of  De- 
cember, 1874,  the  bowels  were  more  regular,  and  there  was  less  headache  and 
irritability;  the  pulse  was  firmer,  and  the  beats  were  seventy-two  per  minute. 

It  may  be  interesting  to  note  that  the  mother  of  these  two  patients,  who 
were  sisters,  suffered  in  the  same  way,  and  that  she  was  for  years  under  the 
late  Dr.  Todd.  She  suffered  from  extreme  meningeal  irritation,  and  re- 
mained in  bed  for  days  together  in  a  darkened  room,  unable  to  eat  a  morsel 
of  food  or  to  retain  a  drop  of  anything  on  her  stomach.  During  a  period 
of  twenty  years,  whilst  these  headaches  lasted,  fears  were  entertained  that 
she  would  lose  her  intellect.  After  the  age  of  sixty  she  ceased  to  suffer  from 
them,  and  is  now  not  only  entirely  free,  but  her  activity  and  powers  of  en- 
durance may  well  be  envied  by  persons  who  are  half  her  age. 

The  following  is  another  example  of  nervous  headache  ;  and  it  presents  an 
assemblage  of  symptoms,  which  prove  unsteadiness  in  the  brain-centre,  and 
a  hypersemic  state  of  the  cerebral  vessels  from  partial  paralysis  and  dilatation. 
It  is  a  matter  of  no  great  importance  whether  the  cause  is  attributable  to 
overindulgence  in  spirituous  liquors,  or  to  excessive  mental  activity.  The 
consequences  and  the  train  of  symptoms  are  much  the  same  in  both  in- 
stances. And  I  must  here  insist  on  the  fact  that  the  true  congestive  head- 
ache has  features  in  common  with  the  nervous  form  in  some  stage  or  degree 
of  the  attack.  F.  H.  B.,  aet.  31,  married,  first  consulted  me  on  December 
5th,  1873,  fo"^  headache,  to  which  he  had  been  subject  since  i860.  He  is 
tall,  slender,  pale,  and  dark,  and  leads  a  life  full  of  intellectual  activity, 
exerting  his  physical  and  mental  strength  to  the  utmost,  and  seldom  taking 
that  allowance  of  rest  which  is  essential  to  the  enjoyment  of  moderate  health. 
Eighteen  years  ago  he  had  scarlet  fever,  succeeded  by  congestion  of  the 
kidneys  and  dropsy.  At  this  time  he  had  agonizing  headache,  leading  to 
effusion  of  the  brain  and  insensibility.  There  is  little  doubt  that  these 
symptoms  were  due  to  the  retention  of  urea  in  the  blood.  When  he  re- 
covered from  this  illness  he  suffered  from  irritative  dyspepsia,  which  lasted 
for  a  year  or  two.  The  attack  of  headache  in  question  came  on  from  dining 
in  the  middle  of  the  day,  and  walking  afterwards.  The  pain  grew  worse 
and  worse,  and  at  length  he  became  sleepy  and  retired  to  bed,  when  he 
seemed  a  little  better.  He  awoke  at  10  p.  m.  with  a  kind  of  muddling  pain, 
and  a  dreadful  feeling  as  though  his  head  was  filled  with  lead,  and  then 
followed  a  sensation  of  stuffiness  and  throbbing.  Sometimes  there  was  a  pain 
as  if  the  head  was  opening  and  shutting.  The  headache  began  in  one  or 
the  other  temple  (formerly  in  the  left  temple)  ;  it  passed  through  to  the 
occiput,  and  extended  down  the  cervical  vertebrae,  rendering  the  muscles  of 
the  neck  stiff  and  painful  to  move  from  a  fixed  position.  The  headaches 
were  sometimes  attended  with  nausea,  and  sometimes  preceded  by  dizziness. 
They  usually  came  on  in  the  morning,  with  a  dull  oppressive  weight  and 
pain ;  but  this  time  he  was  attacked  later  in  the  day,  and,  as  the  pain  grew 
bad,  he  became  cold  and  shivering.  The  urine  was  clear  and  free  from 
albumen,  the  bowels  regular,  the  tongue  slightly  coated ;  the  pulse  72,  small, 
weak,  and  regular.  The  heart  was  healthy,  and  free  from  any  organic  or 
functional  bruit.  The  psychological  symptoms  were  peculiar.  He  would 
feel  he  ought  to  do  a  particular  thing,  but  could  not  bring  his  mind  to  do 
it ;  he  was  playing  at  cross  purposes,  and  contending  between  reason  and 
obstinacy.  He  would  not  allow  his  wife,  whom  he  loved,  to  come  near 
him;  but  he  would  allow  the  nurse,  whom  he  hated.  He  was  irritable,  and 
knew  intuitively  the  remedy  of  three  which  would  abate  the  headache  ;  but 
unless  his  attendants  could  find  out  which  it  was,  he  was  so  perverse  that  he 
would  not  tell  them ;  and  if  they  brought  the  wrong  one,  he  was  frantic  and 


NERVOUS    HEADACHE.  73 

uncontrollable.  In  this  respect  he  resembled  his  child,  who  also  suffered 
from  a  similar  form  of  headache.  When  he  was  overtaken  with  these  head- 
aches he  could  not  keep  still  or  lie  down,  but  was  perpetually  walking  about. 
As  to  remedies,  an  emetic  was  one  of  the  most  speedy  and  effectual ;  but  the 
quickest  remedy  of  all  was  a  mustard  poultice  applied  to  the  back  of  the 
neck,  the  feet  being  immersed  in  warm  water.  This  sent  him  soundly  to 
sleep  in  half  an  hour.  The  day  after  the  headache  was  simply  one  of  dul- 
ness  and  inactivity,  and  if  he  exerted  himself  it  would  return. 

I  ascertained  in  May,  1876,  that  this  patient's  headaches  were  less  acute, 
less  frequent,  and  less  inevitable  than  formerly,  and  that  there  was  less  per- 
versity and  violence  of  manner.  A  dull  heavy  feeling  frequently  threatens, 
but  gives  way  to  rest  or  treatment.  Hot  water  to  the  feet,  and  rest,  are 
still  the  two  chief  remedies  he  relies  upon.  He  still  uses  a  mustard  poultice 
to  the  neck  when  the  pain  is  very  bad,  but  this  now  very  rarely  happens. 
Brandy  never  gives  the  slightest  relief;  and  music,  which  at  one  time  seemed 
to  arrest  the  headaches  magically,  has  no  effect  at  all  now. 

The  following  is  an  example  of  nervous  headache  of  the  severe  type,  not 
promising  great  benefit  from  treatment  unless  the  occupation  and  habits  of 
life  can  be  entirely  changed. 

S.  B.  T.,  set.  43,  m.,  consulted  me  May  31st,  1877.  Has  served  twenty- 
seven  years  as  an  officer  in  the  Indian  army,  and  during  this  time  experi- 
enced good  health  except  on  two  occasions.  The  patient  was  thin  and 
spare,  of  energetic  habits,  and  nervous  temperament. 

In  1857  he  had  severe  malarious  fever,  which  compelled  him  to  return  to 
England  for  eighteen  months. 

In  1867-8  he  held  a  responsible  and  anxious  post  during  the  Abyssinian 
war;  the  strain  of  mind  and  body  was  so  great,  that  at  the  end  of  the  expedi- 
tion he  was  compelled  to  return  to  England,  when  he  suffered  chiefly  from 
sleeplessness  and  disinclination  for  mental  work.  Two  years'  residence  in 
this  country  completely  set  him  up,  and  he  returned  to  India  in  July,  1870, 
quite  recovered. 

In  1872  he  was  subjected  to  severe  mental  distress,  and  about  this  time 
continuous  (as  distinct  from  occasional^  headaches  commenced,  and  from 
these  he  is  still  suffering. 

He  thus  writes:  "I  appear  to  suffer  from  two  distinct  headaches;  the  one 
occurs  only  at  distant  intervals,  varying  from  one  to  three  months;  the 
other  is  continuous.  The  occasional  headache  gives  some  notice  of  its  ap- 
proach, feeling  out  of  sorts  for  a  day  or  two  previously.  It  commences  soon 
after  awaking  in  the  morning,  and  increases  in  intensity  during  the  day; 
the  pain  is  distracting,  head  hot,  with  sense  of  fulness,  extremities  cold,  and 
nervous  twitching.  Cannot  bear  a  reclining  position  for  a  moment,  but 
compelled  to  keep  constantly  walking  up  and  down,  till  sometimes  ready  to 
drop  from  fatigue ;  when  pain  moderates  sufficiently  to  make  sleep  possible, 
still  obliged  to  avoid  a  recumbent  posture,  and  get  my  first  sleep  either  in  a 
chair,  or  propped  up  with  pillows  in  bed.  These  attacks  leave  no  trace 
behind,  except  a  little  shakiness  next  day.  A  strong  saline  draught  some- 
times shortens  their  duration,  and  in  unusually  severe  attacks,  an  ice-bag 
to  the  head,  and  occasionally  (though  seldom)  I  inhale  a  little  chloroform 
to  deaden  pain,  but  not  sufficient  to  cause  insensibility. 

"The  continuous  headache  first  commenced  about  five  years  ago,  shortly 
after  the  mental  strain  in  1872.  At  first  symptoms  slight ;  would  wake  in 
the  morning  feeling  unrefreshed,  and  with  a  most  uncomfortable  sense  of 
giddiness  and  weight  in  the  head;  this  would  generally  go  off  at  ten  or 
eleven  o'clock. 


74  HEADACHES, 

"  But  by  degrees  the  periods  of  freedom  from  discomfort  became  shorter; 
there  was  difficulty  in  getting  sleep;  would  constantly  go  to  rest  and  sleep 
well  for  an  hour  or  so,  and  then  awake  and  be  unable  to  sleep  for  several 
hours,  generally  getting  up  and  reading  in  the  intervals.  There  was  great 
disinclination  for  mental  work,  and  a  putting  off  from  day  to  day  of  business, 
or  duties,  which,  when  circumstances  compelled  to  be  taken  in  hand,  were 
transacted  on  the  spur  of  the  moment  with  satisfaction." 

As  he  continued  in  this  state  for  four  years,  not  growing  better,  but  on 
the  whole  worse,  he  was  obliged  to  return  to  England — in  May,  1876. 

He  has  derived  no  benefit  at  present  from  being  in  England,  as  he  suffers 
continually  from  this  headache. 

The  symptoms  are  so  variable  that  it  is  difficult  to  describe  them  with 
precision.  As  a  rule,  there  is  a  dull  heavy  pain  in  the  head,  accompanied 
with  giddiness  and  with  throbbing,  which  is  sometimes  so  intense  that  the 
beats  are  distinctly  felt  in  both  ears,  whilst  at  other  times  the  pain  is  slight, 
and  less  of  a  throb  than  a  sort  of  undulating  pulsation. 

There  is  often  pain  immediately  over  the  eyebrows,  great  soreness  of  the 
eyes,  and  unwillingness  to  face  the  light.  The  headache  is  sometimes  in 
the  brow,  when  it  is  generally  accompanied  with  heat  of  surface;  at  other 
times  it  is  confined  to  one  spot  (about  the  size  of  the  palm  of  the  hand)  in 
the  centre  of  the  top  of  the  head,  and  at  others  it  is  over  the  occiput  and 
nape  of  the  neck. 

Again  he  writes  :  "When  very  bad,  every  noise  seems  to  go  through  the 
brain  ;  the  sound  of  talking  in  the  room  is  so  unbearable  that  I  am  compelled 
to  go  away  and  remain  in  a  room  by  myself.  Occasionally  there  is  very 
great  irritability,  and  a  sort  of  weary  restlessness,  inducing  a  constant  desire 
to  travel  about  from  place  to  place.  There  is  unwillingness  to  exert  the 
mind  in  any  way;  reading  is  taken  up  as  a  distraction,  and  as  the  memory 
is  affected  the  subject  is  speedily  forgotten.  Notwithstanding  disinclination 
for  exertion,  the  want  of  regular  occupation  (to  which  I  have  been  long 
accustomed)  is  severely  felt,  and  has,  I  think,  done  more  to  prevent  improve- 
ment than  anything  else. 

"  For  the  first  eight  months  after  returning  from  India,  sleep  Avas  most 
irregular — night  after  night  lying  awake  till  two  or  three  in  the  morning ; 
but  during  the  past  few  months  there  has  been  an  improvement  in  this 
respect,  and  a  broken  night's  i-est  is  the  exception,  and  any  feeling  of  wake- 
fulness yields  to  tincture  of  cannabis  indica  in  twenty-minim  doses,  leaving 
no  unpleasant  effects  next  day. 

"  My  appetite  is  better  than  on  my  first  return  from  India;  digestion 
good.  I  am  temperate,  but  smoke  freely,  and  the  inclination  is  greatest 
when  irritable.  For  the  last  four  months  the  headaches  seem  to  increase  in 
intensity  at  regular  intervals  of  from  fourteen  to  sixteen  days,  and  some- 
times there  is  a  feeling  of  weakness  and  pain  in  the  limbs.  On  returning 
from  India  I  was  examined,  and  the  splee?i  was  found  to  be  tender  on  pres- 
sure, but  the  liver  was  free  from  disease.  Took  podophyllin,  hydrochloric 
acid,  and  taraxacum;  later  on,  took  bromide  of  potassium  three  times  a  day 
for  a  month  without  benefit ;  neither  the  sleeplessness  nor  headache  had 
diminished.  Then  a  blister  was  applied  to  the  neck,  and  arsenic  taken,  with- 
out benefit;  after  this,  strychnine  failed.  Recently  quinine  in  gr.  v.  doses 
was  prescribed,  and  failed,  and  gr.  x.  doses  gave  no  relief. 

"The  headaches  are  not  hereditary  in  our  family,  and  my  brother  is  sin- 
gularly free  from  them,  being  able  to  sav  that  he  has  never  had  a  headache  in 
his  life." 

He  has  been  constantly  moving  about  to  Scotland,  to  Wales,  Folkstone, 


NERVOUS    HEADACHE.  75 

and  Cornwall,  without  deriving  benefit.  Cannot  ascertain  v/hat  causes  the 
headaches ;  they  appear  to  become  more  intense,  and  to  moderate  without 
special  cause  ;  no  medicine  has  any  effect. 

May  31st  (his  first  visit).  Had  intense  weight  this  morning  over  head; 
giddiness  up  to  10  a.  m.,  which  has  left  only  the  feeling  of  weight:  the  pain 
moves  about  from  one  part  of  the  head  to  another.  Tongue  bluish  and 
furred;  pulse  64,  pretty  good,  very  regular;  urine  pale-straw  color,  sp. 
gr.  1020,  and  non-albuminous;  liver  healthy;  heart  weak. 

N.  B. — The  great  feature  of  this  case  is  nervous  exhaustion,  and  a  most 
languid  circulation.  Arsenic,  iron,  and  calumba  were  prescribed  twice  a 
day  (Form.  24  b)  and  bromide  of  ammonium  on  rising  in  the  morning 
(Form.  25).  The  diet  was  ordered  to  be  plain  and  simple,  stimulants  to  be 
avoided,  and  no  tea. 

June  19th.  He  writes :  "  I  think  that,  on  the  whole,  I  can  fairly  say 
that  I  am  better  ;  the  periodical  attack  is  somewhat  less  severe,  and  I  have 
not  suffered  quite  so  much  either  from  giddiness  or  headaches;  but  the 
sense  of  heaviness  and  dullness  still  remain  constant." 

To  continue  cod-liver  oil,  or  malt  extract,  and  Carlowitz  or  claret. 

From  this  account  he  had  evidently  taken  too  much  exertion,  and  fatigued 
himself 

September  30th.  Benefited  and  improved  for  two  months  in  Wales,  but 
when  out  in  the  garden  one  day  picking  strawberries,  the  sun  was  powerful, 
and  beating  fiercely  down  his  back  whist  stooping.  In  the  afternoon  one 
of  his  severe  headaches  came  on,  and  he  has  never  been  well  since.  The 
weather  after  this  was  damp  and  depressing  for  six  weeks  ;  he  felt  weak  and 
depressed  ;  the  chief  new  symptom  was  aching  pain  in  the  small  of  the  back, 
which  he  has  never  lost.  Frequently  he  felt  feverish,  and  on  one  occasion, 
soon  after  the  "sunning,"  had  a  distinct  but  mild  attack  of  ague.  Giving 
up  smoking  did  no  good  ;  the  pain  in  the  back  gives  more  uneasiness  than 
the  headache  itself.  As  he  was  obliged  to  return  to  India,  he  was  advised 
to  avoid  the  heat  of  the  sun,  and  as  much  as  possible  to  live  quietly.  A 
simple  plaster  was  ordered  to  the  back,  and  hydrobromic  acid  and  quinine 
twice  a  day  (Form  14). 

The  origin  of  the  pain  in  migraine  is  supposed  by  some  authorities  to 
reside  in  the  optic  thalami,  and  the  visual  defects  to  originate  in  the  organ 
of  the  affected  side,  and  then  to  extend  downwards  in  the  course  of  the  sen- 
sory tract.  I  must  refer  the  reader  to  the  different  opinions  held  by  Dr. 
Broadbent,  Dr.  Ferrier,  Dr.  Bastian,  and  Dr.  Crichton  Browne.*  The  lat- 
ter writer,  in  speaking  of  the  blood-supply  to  the  great  ganglia  of  the  corpus 
striatum  and  thalamus  opticus,  thus  writes ;  "  But  the  middle  cerebral,  the 
chief  artery  of  the  corpus  striatum,  is  distributed  to  the  motor  regions  of  the 
cerebrum,  while  the  posterior  cerebral,  the  chief  artery  of  the  optic  thala- 
mus, is  distributed  mostly  to  the  sensory  regions  of  the  cerebrum.     These 

*Dr.  Crichton  Browne's  paper  on  the  Functions  of  the  Thalarni  Optici,  in  the  West  Rid- 
ing Lunatic  Asylum  Medical  Reports,  vol.  v.,  1875,  P-  129. 

"  According  to  M.  Hervez,  of  Chegoin,  migraine  is  an  arterial  neurosis  which  takes  its 
origin  in  the  great  sympathetic  nerve,  and  its  seat  is  in  the  nervous  filaments  which  accom- 
pany the  arteries,  whilst  it  manifests  itself  in  the  dilatation  of  these  vessels,  and  in  the  com- 
pression of  the  brain  and  other  organs  it  produces.  The  treatment  of  migraine  consists  in 
combating  the  tendency  to  periodicity,  the  pain  and  the  arterial  dilatation.  M.  Hervez  finds 
the  following  prescription  of  essential  value  in  fulfilling  those  indications.  He  gives  every 
day  one  pill  containing  about  one  grain  of  sulphate  of  quinine,  one  gi'ain  of  tannic  acid,  and 
a  seventy-fifth  of  a  grain  of  aconitina.  The  dose  may  easily  be  increased  to  three  or  four 
such  pills  daily."  [Journal  de  Medirine,  December,  1876.) — Quoted  from  the  Practitiotier, 
March,  1877,  p.  197. 


^6  HEADACHES. 

facts  surely  suggest  the  intimate  association  of  tlie  corpus  striatum  with 
.  motor,  and  of  the  optic  thalamus  with  sensory  functions." 

In  some  few  instances  I  have  know  the  hair  to  fall  off  from  continued  ner- 
vous headache,  and  when  this  happens  the  scalp  becomes  the  seat  of  great 
irritation,  with  troublesome  pityriasis.  Both  Cazenave  and  Neligan  have 
observed  the  same.*  Two  cases  are  in  my  recollection  where  the  scalp  be- 
came the  seat  of  so  much  irritation  that  the  patient  could  not  summon  up 
sufficient  fortitude  to  resist  scratching  her  head  incessantly.  The  itching, 
tingling,  and  the  abundant  desquamation  of  white-brownish  scales,  are  in- 
variably increased  after  each  paroxysm  of  headache.  I  have  so  often  noticed 
the  co-existence  of  dandruff  with  imbricated  scales  in  those  who  have  suffered 
from  confirmed  nervous  headache,  that  it  must  be  more  than  accidental.  It 
is  a  constitutional  affection,  in  which  the  nervous  system  is  largely  con- 
cerned, and  the  most  frequent  cases  in  my  experience  have  been  in  women 
about  the  middle  period  of  life,  who  have  suffered  from  catamenial  disturb- 
ance. It  is  not  improbable  that  a  local  irritation  may  be  induced  through 
the  branches  of  the  fifth  nerve,  as  they  ramify  over  the  scalp,  and  so  lead  to 
an  excessive  secretion  from  the  sebaceous  glands.  When  the  greasy  scales 
so  formed  are  allowed  to  remain,  they  become  dry  and  brown,  and  in  some 
few  cases  the  scalp  underneath  is  tender  and  reddened.  But  it  is  import- 
ant to  disting-uish  the  disease  from  eczema,  which  may  generally  be  done 
without  difficult)^ ;  true  pityriasis  being  characterized  by  an  absence  of  ex- 
udation and  albuniinous  secretion.  A  weak  ointment  of  nitric  oxide  of  mer- 
cury is  an  excellent  application  (Form.  114  a). 

Another  curious  affection  of  the  skin  is  sometimes  observable  in  women 
about  the  middle  period  of  life,  who  are  great  sufferers  from  nervous  and 
neuralgic  headache,  patients  who  have  endured  severe  pain  for  years,  and 
who  are  much  exhausted  in  consequence.  Their  dark  shrivelled  eyelids  and 
blank  expression  of  the  face  attest  the  fact  beyond  doubt.  The  complaint 
to  which  I  allude  is  known  as  Xanthelasma  Palpebraj-um.  "  The  patholog- 
ical nature  of  this  affection  is  an  hypertrophy  and  altered  color  of  the  epithe- 
lium of  the  sebiparous  gland  and  of  its  execretory  tubuli."  f  It  is  a  new 
growth  of  connective  tissue  infiltrated  with  an  oily  material  which  imparts  to 
the  discolored  integument  the  buff  or  yellow  color.  The  disease  consists  in 
defined  patches  of  discolored  skin,  of  irregular  outline,  occupying  the  upper 
and  lower  eyelids  at  the  inner  canthus.  They  are  variable  in  color,  some- 
times being  of  an  orange  or  lemon  tint,  but  that  of  chamois  leather,  or 
nankeen,  is  a  good  resemblance.  They  are  smooth  and  soft,  and  look  like 
caseous  matter  immediately  beneath  the  skin.  The  patches  are  not  attended 
with  pain  or  irritation,  and  they  never  ulcerate  nor  suppurate.  They  are 
generally  looked  upon  as  permanent  and  incurable,  but  Professor  Erasmus 
Wilson  says  he  succeeded  in  removing  the  disorder  in  one  patient  by  the 
application  of  compound  tincture  of  iodine,  and  by  the  internal  exhibition 
of  arsenic. t 

Treatment. — Here  a  task  of  exceeding  difficulty  lies  before  any  writer, 
and  no  amount  of  experience  enables  him  to  lay  down  any  uniform  plan  for 
adoption  and  guidance.  Every  case  must  be  treated  on  its  own  merits;  ab- 
solute and  binding  rules  are  useless.  A  method  of  treatment  which  has  an- 
swered our  expectations  in  one  case  is  futile  and  barren  of  results  in  the 

*  Neligan,  On  Diseases  of  the  Skin,  1852,  p.  250.  The  late  Dr.  Anstie  after  each  attack 
went  gray  over  the  temple  which  was  subject  to  neuralgia. 

J  Diseases  of  the  Skin,  by  Erasmus  Wilson,  F.  R.  S.,  1S63,  p.  619. 
J  Op.  cit.,  1863,  p.  620. 


NERVOUS    HEADACHE.  7/ 

next ;  the  misery  pursues  a  determined  progress  till  the  attack  is  over. 
Practically,  then,  the  patient  resigns  himself  to  his  fate,  till  the  nerve-storm 
has  worn  itself  out  by  excessive  expenditure,  and  sleep  has  readjusted  the 
tremulous  circulation  within  the  head.  If  we  can  induce  the  patient  to  alter 
the  habits  of  his  life,  we  may  hold  out  the  prospect  of  arresting  the  fre- 
quency of  these  headaches ;  and,  moreover,  we  shall  bestow  some  ease  and 
comfort,  if  we  can  fortify  the  general  health  to  resist  them,  till  increasing 
years  and  physiological  changes  in  the  different  organs  of  the  body,  render 
the  patient  no  longer  susceptible  to  them.  In  one  instance  constant  change 
of  scene  and  place,  by  occupying  the  patient's  mind  with  new  ideas  and 
pleasant  thoughts,  kept  the  disease  at  bay.  We  may  lay  down  golden  rules, 
but  the  circumstances  of  life  seldom  admit  of  their  being  observed  faithfully 
or  consistently.  A  man  is  obliged  to  live  in  a  large  town,  and  from  bad  air 
and  want  of  exercise  he  gets  severe  headaches  ;  if  he  resides  in  the  country 
he  loses  them.  But  he  has  no  choice  of  residence  ;  his  lot  has  fallen  among 
the  noise  and  crowd,  where  all  is  hurry  and  excitement,  and  he  is  driven 
forward  with  the  throng,  as  feeble  to  oppose  it  as  the  stream  of  a  gentle  riv- 
ulet is  to  reverse  the  course  of  the  mountain  torrent  into  which  it  falls. 

When  a  nervous  headache  is  threatening,  the  patient  should  lie  down  and 
observe  the  strictest  seclusion  and  rest;  and  if  this  be  done  at  an  early  stage, 
a  severe  attack  may  sometimes  be  averted  altogether.  The  sudden  influx  of 
light  when  the  curtains  are  drawn  up  of  a  morning  in  a  dark  bedroom,  may 
instantaneously  cause  the  return  of  a  bad  attack,  previously  stopped  by  a 
good  night's  rest.  Mr.  May,  of  Reading,  once  had  under  his  care  a  most 
remarkable  case  of  a  lady  subject  for  years  to  "  intense  headache  and 
intolerance  of  light,  commencing  on  first  awaking  in  the  morning,  and 
persisting  more  or  less  all  day."  The  immediate  effect  of  the  first  influx  of 
light  was  to  cause  a  severe  frown,  followed  by  headache.  Mr.  May  cured 
the  patient  by  covering  one  eye  with  a  card  to  which  was  attached  an  elastic 
tape,  and  this  was  passed  around  the  head,  so  as  to  slightly  compress  the 
occipito-frontalis  and  corrugators.  "  The  simple  device  effectually  prevented 
the  frown,  and  there  was  at  once  an  end  to  the  mischief."  The  eyes  were 
afterwards  gradually  accustomed  to  light  by  being  alternately  covered  and 
uncovered  by  the  card  for  two  hours  at  a  time,  so  as  to  regulate  the  ad- 
mission of  light.  The  patient  completely  recovered,  and  remained  free  from 
headache  till  her  death,  about  eighteen  years  later.* 

When  persons  derive  benefit  from  lying  in  a  recumbent  posture,  and 
taking  a  glass  of  wine  or  some  other  diffusible  stim^ulant,  at  the  beginning  of 
the  attack,  the  cerebral  vessels  are  insufficiently  supplied  with  blood ;  and 
hence,  by  stimulating  the  heart's  action,  the  blood  is  propelled  to  the 
cranium  with  increased  force,  and  relief  is  obtained.  This  is  the  stage  and 
form  of  headache  where  people  (especially  fashionable  ladies)  overfatigued 
from  driving  and  excitement  in  the  London  season,  lose  their  headaches  as 
the  dinner  advances,  and  they  consume  more  wine  than  is  advisable.  The 
feet  and  hands  are  often  cold  at  this  stage,  the  skin  is  shrivelled  and  dry, 
and  the  pulse  is  slow  and  weak ;  there  are  in  some  cases  glimmering  flashes 
of  light  before  one  or  both  eyes,  and  the  patient  is  depressed,  prostrate  and 
helpless.  She  both  feels  and  looks  wretchedly  miserable.  When  altered 
sensation  has  not  entirely  merged  into  pain,  irritability,  agitation,  and 
disquietude  are  the  prevailing  features  of  the  aff'ection.  Now,  I  believe  that 
if  a  stimulant  is  to  be  of  any  service,  it  should  be  given  at  the  onset  of  the 

*  The  case  is  reported  by  Mr.  Hilton  in  his  lectures  On  Rest  and  Pain,  2d  edition,  1877, 
p.  147- 


78  '  HEADACHES. 

symptoms ;  and  if  there  exist  nausea,  or  more  certain  derangement  of  the 
digestive  organs,  we  shall  certainly  increase  the  evil  by  the  exhibition  of  a 
stimulant.  And  why?  Because  the  ganglia  of  the  sympathetic  nervous 
system,  being  exceedingly  impressible,  transfer  the  irritation  from  the 
splanchnic  and  gastric  nerves  to  the  nervous  centres  in  the  bram,  causing 
the  vessels  to  become  unduly  dilated  through  the  action  of  the  vasomotor 
nerves,  and  so  the  headache  becomes  more  violent  and  throbbing  than  when 
the  encephalic  supply  of  blood  is  diminished. 

During  the  acute  stage  of  a  severe  nervous  headache  there  is  so  little  to  be 
done  that  it  is  the  best  plan  to  leave  the  patient,  alone  and  quiet,  in  a  dark- 
ened room.  Beyond  applying  cold  to  the  head  by  means  of  a  sponge  wrung 
out  of  cold  water,  or  the  ice  cap  previously  spoken  of,  there  is  nothing  to  be 
done.  Interference  is  cruelty.  If  we  put  anything  into  the  stomach,  we 
shall  increase  the  nausea  and  aggravate  the  pain.  I  have  sometimes  known 
a  warm  bath,  and  afterwards  a  bottle  of  hot  water  to  the  extremities,  afford 
relief,  by  dilating  the  systemic  vessels,  and  in  some  way  altering  the  circula- 
tion within  the  head.  If  the  pulse  is  good,  and  the  face  is  at  all  flushed,  an 
emetic  of  mustard,  or  a  scruple  of  sulphate  of  zinc  (Form.  io8),  will  rid 
the  stomach  of  any  offensive  matters,  and  give  immediate  ease.  But  it  often 
happens  that  the  nausea  is  extreme  when  the  stomach  is  empty,  or  after 
vomiting  has  continued  some  time. 

In  these  cases  it  is  best  to  try  and  relieve  the  sickness,  and  for  this  purpose 
hydrocyanic  acid  may  be  given  alone  (Form.  41),  or  with  citrate  of  potash 
in  effervescence  (Form.  42).  A  mustard  poultice,  or  a  small  mustard  leaf 
to  the  epigastrium,  or  at  the  back  of  the  neck,  and  a  piece  of  ice  to  suck, 
are  also  worth  trying.  Soda-water  and  a  little  dry  champagne  or  brandy 
sometimes  answer  well,  and  the  patient  may  at  once  feel  relief  and  fall  asleep 
afterwards ;  but  very  frequently  any  stimulant  of  this  character  aggravates 
all  the  symptoms,  and  I  now  never  resort  to  it  unless  the  patient  is  pale  and 
exhausted.  An  active  aperient  pill  given  the  night  before  the  attack  is  threat- 
ening, or  an  ounce  of  the  compound  decoction  of  aloes,  will  often  avert  the 
pain  altogether  after  two  or  three  actions  of  the  bowels  (Form.  43),  if  the 
patient  will  remain  perfectly  quiet  in  her  room  the  next  day,  and  take  the 
lightest  diet,  and  carbonate  of  ammonia,  potash,  and  quinine  in  efferves- 
cence'(Form.  44)  ;  but  if  she  persists  in  getting  up  and  resuming  her  duties, 
the  mind  is  put  upon  the  stretch  too  early,  and  headache  returns  in  its  worst 
forms. 

When  the  headache  is  coming  on,  the  patient  is  irritable  and  can  obtain 
no  sleep,  a  mixture  of  bromide  of  potassium,  sal  volatile,  and  camphor- 
water  may  be  given  with  great  advantage  (Form.  26). 

If  the  patient  too  is  in  any  way  excited,  as  the  attack  threatens,  and  there 
are  transient  flushings  of  the  face,  and  a  sense  of  overpowering  heat  and 
faintness  (by  no  means  uncommon  in  women  at  the  climacteric  period),  a 
full  dose  of  bromide  of  potassium  will  be  extremely  beneficial  by  allaying 
the  mental  disquietude  and  subduing  the  excitement  on  which  the  distressing 
symptoms  depend.  If  it  is  given  at  the  right  moment,  before  the  headache 
has  set  in  completely,  it  will  frequently  arrest  the  approaching  paroxysm 
altogether;  the  patient  will  fall  into  calm  sleep,  and  wake  up  well,  provided 
she  will  aid  the  cure  by  absolute  repose. 

Valerianate  of  zinc  is  a  remedy  which  often  proves  serviceable  in  nervous 
headache,  if  there  is  no  sickness,  and  if  the  pain  is  chiefly  on  one  side  of 
the  head.  It  is  a  powerful  nervine  tonic,  and  may  possibly  exert  some  phy- 
siological effect  on  the  nervous  centres.  It  may  be  given  alone  in  the  form 
of  a  pill,  or  with  quinine  or  rhubarb  (Form.  87).     If  the  headache  is  asso- 


NERVOUS    HEADACHE.  79 

ciated  with  ansemia,  it  may  be  ordered  in  combination  with  sulphate  of  iron 
(Form.  97).  The  late  Dr.  Symonds  was  in  the  habit  of  prescribing  oxide 
of  zinc,  extract  of  valerian,  and  extract  of  hyoscyamus  together;*  and  Dr. 
E.  Liveing  quotes  a  case  of  paroxysmal  headache  completely  cured  after  the 
administration  of  twenty-four  grains  of  valerianate  of  zinc.f 

Oxide  of  zinc  alone  has  been  found  of  use  in  a  few  cases  (Form.  98). 
Oxide  of  silver  in  half-grain  doses,  with  two  grains  of  extract  of  hyoscy- 
amus in  a  pill  at  bedtime,  effectually  removed  an  obstinate  nervous  headache 
due  to  irritation  of  the  sympathetic  nerve,  after  the  failure  of  other  remedies. 

Full  doses  of  hydrochlorate  of  ammonia  are  also  to  be  mentioned  as  de- 
serving a  trial  in  these  cases,  when  the  physician  is  driven  to  his  wits'  end 
(Form.  27).  If  the  pain  is  chiefly  confined  to  a  spot  or  small  space  on  one 
side  of  the  head,  belladonna  or  aconitina  ointment  may  be  rubbed  into  the 
temple  at  the  same  time  (Form.  110-113),  and  quinine  persevered  with,  as 
in  the  neuralgic  variety  of  the  affection.  When  quinine  causes  headache, 
it  is  well  to  combine  it  with  hydrobromic  acidj  (Form.  14).  I  am  in  the 
habit  of  prescribing,  with  much  advantage  in  these  cases,  the  bromide  of 
potassium  and  tincture  of  quinine  together  (Form.  13),  and  I  am  fully  satis- 
fied that  the  headache  and  nervous  excitability  would  have  increased  by  the 
employment  of  the  quinine  alone. 

I  knew,  many  years  ago,  a  young  lady  who  obtained  relief  from  a  nervous 
headache  by  drinking  a  tumblerful  of  warm  water  twice  or  three  times  a  day, 
and  this  she  sometimes  did  with  equally  good  effect  at  meal  times. 

The  inhalation  of  chloroform  in  acute  nervous  headache  sometimes  con- 
trols the  severity  of  the  paroxysm,  and  induces  sleep ;  but  if  there  is  any 
nausea  it  is  rarely  of  service,  and  usually  provokes  vomiting,  which  distresses 
the  patient  and  increases  the  suffering. 

Guarana  has  not  proved  a  successful  remedy  in  the  few  cases  in  which  I 
have  employed  it,  but  many  medical  men  have  borne  testimony  to  its  efficacy  on 
the  first  symptoms  of  headache  making  their  appearance.  It  may  be  given  in 
doses  of  15  or  20  grains  in  water  with  an  equal  quantity  of  sugar,  and  re- 
peated in  half  an  hour  if  it  does  not  afford  relief.  Dr.  Latham  speaks  well  of 
it  when  there  is  glimmering  in  the  field  of  vision,  pain  in  one  temple,  and 
nausea  or  vomiting.  II  Dr.  Wilks  also  gives  testimony  in  favor  of  it.§  As 
it  appears  to  stimulate  the  vasomotor  nerves,  and  so  to  diminish  the  supply 
of  blood  to  the  brain,  it  would  have  no  good  effect,  probably,  in  the  early 
or  premonitory  stage,  when  there  was  disturbance  of  the  vision ;  but  at  a 
later  stage,  if  the  headache  is  severe  and  attended  with  throbbing  of  the 
temporal  arteries,  it  may  succeed  when  the  bromides  and  other  remedies  fail. 
This  remedy  is  also  of  service  in  the  genuine  neuralgic  headaches  (hemi- 
crania). 

When,  in  a  case  of  this  character,  the  face  is  pallid  and  the  pulse  weak 
and  slow,  and  the  patient  is  beginning  to  feel  the  want  of  sleep,  there  is  no 
remedy  equal  to  the  hypodermic  injection  of  morphia.^     It  may  be  always 

*  Gulstonian  Lectures  on  Headache,  in  Medical  Times  and  Gazette,  1858,  vol.  xvi.,  p.  496. 

f  On  Megrim  and  Sick  Headache,  1873,  p.  448. 

%  The  formula  for  preparing  the  hydrobromic  acid  is  given  in  a  short  paper  by  Dr.  J.  Mil- 
ner  Fothergill  in  the  British  Medical  Journal,  July  8th,  1876,  p.  40. 

II  Dr.  Latham,  on  Nervous  or  Sick  Headache,  p.  69. 
\  Medical  Times  and  Gazette,  January  2,  1869. 

^  "  The  quick  and  powerful  action  of  morphia  and  other  narcotics,  when  injected 
beneath  the  skin,  affords  a  familiar  illustration  of  the  fact  that  a  current  of  liquid  is  con- 
stantly passing  from  the  tissues  into  the  blood;  the  blood  being,  of  course,  the  vehicle  by 


80  HEADACHES, 

used  with  the  greatest  safety  if  the  quantity  is  small  to  begin  with,  and  the 
patient  needs  sleep.  Nothing  has  so  realized  my  expectations  in  those  pure 
forms  of  nervous  headache,  where  I  think  it  more  likely  that  the  nervous 
centres  are  in  a  state  of  extreme  susceptibility  than  that  the  calibre  of  the 
vessels  is  changed.  If  it  does  not  completely  remove  the  pain,  it  induces 
sleep,  or  gives  that  amount  of  repose  which  renders  the  patient  indifferent 
to  all  that  goes  on  around  him  ;  and  in  this  way  the  brain  gets  rest  from 
those  harassing  thoughts  and  miserable  speculations  which  haunt  the  poor 
sufferer,  and  from  which  there  is  no  escape.  I  repeat  what  I  have  elsewhere 
written,  as  it  bears  on  some  points  under  consideration.*  When  the  sickness 
and  prostration  are  extreme,  and  nothing  can  be  retained  on  the  stomach, 
not  so  much  as  a  little  iced  water ;  when  the  extremities  are  cold  and  the 
pulse  feeble ;  when  there  is  intolerance  of  light  and  sound,  and  the  patient 
has  been  days  without  getting  any  relief ;  the  one-sixth  of  a  grain  of  acetate 
of  morphia  for  an  adult  will  be  sufficient  to  insure  sleep,  and  the  patient  will 
wake  up  without  headache,  if  not  well.  Sometimes  the  addition  of  the  8oth 
to  the  40th  of  a  grain  of  atropia  will  exert  an  antagonistic  effect,  and  com- 
bat the  tendeney  to  sickness  which  morphia  alone  frequently  excites  (Form. 
116). 

In  cases  of  nervous  headache  I  have  lately  used  the  hypodermic  injection 
at  once,  without  waiting  for  the  effects  of  other  remedies,  and  seen 
immediate  relief  follow.  I  would  urge  the  employment  of  the  remedy  when 
the  patient  is  distracted  with  agony,  though  the  pulse  be  slow  and  weak, 
and  the  features  collapsed.  There  will  be  no  risk  of  employing  it  at  this 
stage  of  depression,  if  the  sufferer  has  been  accustomed  to  the  subcutaneous 
injection  of  the  drug.  On  one  occasion  I  found  that,  after  a  few  hours'  rest 
and  repose  (during  which  time  the  surface  becomes  warmer  and  the  pulse 
improves),  the  pain  and  sickness  returned,  but  with  less  intensity;  then, 
after  retching  had  continued  some  few  minutes,  the  stomach  was  able  to 
retain  a  teaspoonful  of  brandy  and  two  ounces  of  soda-water,  after  which 
the  patient  fell  asleep  for  several  hours.  This  treatment  has  cut  the  parox- 
ysm short,  and  recovery  has  been  much  more  rapid ;  the  terrible  confusion 
of  ideas  and  nervous  excitability  have  been  prevented,  and  the  prostration 
after  the  attack  has  not  been  so  tedious  and  lingering.  I  consider,  however, 
that  the  system  tolerates  the  injection  better  at  a  more  advanced  stage,  when 
the  excitement  is  abated,  and  the  patient  is  worn  out  for  want  of  sleep. 

In  the  intervals  of  the  suffering  we  may  reasonably  expect  to  mitigate  the 
severity  and  frequency  of  the  paroxysms,  provided  the  patient  can  and  will 
carry  out  our  instructions. 

When  a  severe  headache  has  passed  off,  the  stomach  is  often  deranged 
from  the  remedies  employed  or  the  sympathetic  disturbance  set  up  in  the 
various  organs.  Here  an  alkali,  with  the  aromatic  spirit  of  ammonia  and  a 
vegetable  bitter,  has  a  good  effect  (Form  45),  and  a  mild  aperient  pill  at 
bedtime  (Form.  99),  particularly  a  small  quantity  of  iron  with  aloes  and 
myrrh,  to  empty  the  large  bowel  (Form.  85-86). 

When  the  tongue  is  clean  and  the  secretions  are  in  proper  order,  iron  in 
effervescence  is  a  valuable  remedy  twice  or  three  times  a  day  after  food,  and 
sometimes  strychnia  may  be  added  to  improve  digestion  and  accelerate  the 

which  the  absorbed  morphia  reaches  and  acts  upon  the  nervous  centres." — "  On  Certain 
Physiological  Phenomena  connected  with  the  Circulation,  Respiration,  Secretion,  and 
Nutrition,"  by  George  Johnson,  M.  D..  F.  R.  S.,  in  British  Medical  Journal,  January  ist, 
1876,  p.  7. 

*0n  the  Treatment  of  Different  Forms  of  Headache,  in  The  Lancet,  vol.  i,  1875,  June 
19th,  p.  854. 


NERVOUS    HEADACHE.  8  I 

capillary  circulation  (Form.  46).  In  the  case  of  women,  where  the  men- 
strual functions  are  deficient  and  the  bowels  sluggish,  five  grains  of  the  iron 
and  aloetic  pill  of  the  British  Pharmacopoeia  (Form.  85)  will  answer  well, 
whilst  the  the  nitro-muriatic  acid  in  infusion  of  quassia,  with  small  doses  of 
strychnia,  may  be  employed  during  the  day,  or  the  tincture  of  nux  vomica, 
which  answers  better  with  some  persons  (Form.  47-48).  A  dinner  pill, 
given  daily  before  luncheon,  will  sometimes  prove  of  great  service  (Form. 
77),  or  one  or  other  of  the  formulae  (78-100-101). 

In  cold  weather,  if  the  nutrition  of  the  body  is  much  impaired,  cod-liver 
oil  will  be  found  of  great  service,  and  a  teaspoonful  may  be  given,  after  the 
two  chief  meals  of  the  day,  in  a  little  of  Morson's  pepsin  wine  or  orange 
wine.  But  fresh  wine,  air,  exercise,  and  relaxation  of  mind  and  body,  are 
the  chief  remedies  on  which  to  rely. 


CHAPTER    VIII. 

NERVO-HYPER^MIC    HEADACHE. 

Condition  of  the  Cerebral  Vessels,  and  Diagnosis  from  Nervous  Headache — Most  common 
in  Men  who  indulge  in  Stimulants  and  whose  brain  is  overworked  at  the  same  Time — 
Symptoms  indicate  Nervous  Exhaustion,  with  Depression  of  Spirits  and  Loss  of  Appetite 
— Excitability  of  Manner  and  Annoyance  from  Trivial  Causes — Frequently  met  with  in 
Young  Persons  of  both  Sexes — Use  of  an  Emetic — Aperients — Alkalies — Occasional 
Utility  of  Opium — Bromide  of  Potassium  and  Chloral. 

I  INTEND  by  this  term  to  imply  a  form  of  headache  in  which  the  nervous 
element  is  concerned,  and  the  vessels  of  the  brain  are  overloaded  and  in  a 
state  of  vascular  irritation.  It  is  by  far  the  most  common  form  of  conges- 
tion, and  fully  one-half  the  cases  that  seek  relief  are  to  be  classified  under 
this  head  ;  at  least  this  holds  good  with  male  subjects.  At  one  stage  or 
another  the  nervous  headache  indicates  that  the  vessels  of  the  brain  are  con- 
gested, because  it  is  liable  to  paroxysms  of  severity  from  any  exciteuient  or 
noise,  hot  rooms,  or  eating  and  drinking.  There  is  not  the  same  amount  of 
prostration  and  helplessness,  which  are  the  striking  features  of  the  nervous 
headache.  It  belongs  to  persons  whose  circulation  is  excitable,  and  to  those 
who  are  impulsive  and  undisciplined,  or  who,  from  the  force  of  circum- 
stances, have  no  alternative  but  to  work  on  and  abide  the  consequences.  It 
is  met  with  in  men  whose  brains  are  overworked,  and  whose  meals  are  hur- 
riedly taken,  especially  if  at  the  same  time  they  indulge  freely  in  wine  and 
spirits,  and  do  not  get  a  full  allowance  of  sleep.  These  persons  are  liable  to 
flatulence ;  they  have  a  coated  tongue  in  the  morning,  and  a  dry,  unpleas- 
ant taste  in  the  mouth ;  the  breath  is  hot  and  offensive,  and  there  is  thirst 
and  a  total  loss  of  appetite.  Such  persons  go  on  working  against  time  with 
an  ardor  and  zeal  which  they  feel  to  be  irresistible.  They  appear  to  know 
that  the  speed  with  which  they  are  carried  along  is  detrimental,  and  that 
soon  they  must  yield  in  the  contest ;  and  yet,  unless  they  give  up  work  al- 
together, they  have  no  power  of  moderation.  Control  is  gone.  This  con- 
dition of  the  brain  makes  men  really  nervous  ;  if  they  can  be  convinced  of 
the  mischief  that  may  come,  they  slacken  the  speed  for  a  time,  and  in  some 
instances  when  they  find  the  weight  of  the  symptoms  pressing  upon  them 
the  reckless  fortitude  is  abandoned  for  complete  surrender,  and  the  whole 
aspect  of  the  man's  manner  and  life  is  changed. 

With  this  exhaustion,  and  partial  or  general  congestion  of  the  brain,  there 
is  great  nervousness,  with  lowness  of  spirits  and  depression.  The  appetite, 
however,  in  many  cases  is  natural,  and  the  sleep,  may  be  good,  or,  what  is 
more  common,  the  patient  feels  inclined  to  sleep  after  dinner,  but  when  he 
gets  to  bed  is  wakeful  and  restless,  turning  about  from  side  to  side ;  his  mind 
is  busy  with  strange  ideas,  or  he  is  morbidly  solicitous  about  himself  or 
others.  Then  in  the  morning  he  wakes  unrefreshed  and  eats  his  breakfast  in 
a  hurry.  If  he  is  vexed  or  annoyed,  he  can  scarcely  prevent  himself  from 
going  into  great  passion  and  rage.  He  feels  a  rush  of  blood  to  the  head, 
and  a  passing  sensation  of  momentary  unconsciousness.  His  scalp  is  hot, 
the  capillaries  of  the  face  injected,  and  the  eyelids  are  wearied  and  tremu- 
lous. For  the  rest  of  the  day  (and  for  some  time  afterwards,  it  may  be)  his 
legs  and  knees  feel  as  if  they  would  give  way  under  him,  and  he  does  not 

(82) 


NERVO-HYPER^MIC    HEADACHE.  83 

walk  securely.  If  he  has  been  in  the  habit  of  riding,  he  has  no  confidence 
in  the  saddle,  and  any  sudden  movement  of  the  horse  drives  the  blood  to 
the  face  and  head.  Such  a  patient  as  this  may  pass  an  excessive  quantity  of 
lithic  acid  in  the  urine,  especially  if  he  is  of  gouty  or  rheumatic  diathesis ; 
but  it  more  frequently  happens  that  the  urine  is  copious  and  clear,  of  acid 
reaction,  and  of  low  specific  gravity.  In  one  patient,  whose  case  chiefly 
furnished  these  remarks,  the  urine  contained  a  copious  quantity  of  phos- 
phates, when  the  headache  and  nervousness  were  severe ;  and  I  never  noted 
their  absence  with  this  state  of  the  head. 

A  good  example  of  this  headache  is  also  seen  in  women  at  the  change  of 
life,  whose  constitution  till  this  time  has  been  sound  and  good,  and  the  mind 
properly  balanced.  The  catamenia  have  been  regular  up  to  the  age  of  forty- 
five  or  thereabouts,  and  then  somewhat  suddenly  they  have  become  sluggish, 
or  irregular  and  scanty.  At  each  returning  period  there  has  been  headache 
across  the  forehead,  and  weight  over  the  eyes.  The  patient  complains  of 
flushes  of  heat,  and  the  head  and  scalp  are  hot.  Any  allusion  to  her  condi- 
tion drives  the  blood  to  her  cheeks,  and  a  dry  skin  is  succeeded  by  a  hot 
oppressive  perspiration,  with  faintness  and  languor.  She  sleeps  badly,  and 
sees  dark  spots  before  her  eyes;  she  cannot  concentrate  her  attention  on  her 
household  duties ;  and  her  children  vex  her,  and  easily  put  her  out.  She  is 
made  jealous  and  excitable  without  reason,  and  magnifies  into  questions  of 
great  moment  trifling  circumstances,  to  which  at  other  times  she  would  not 
pay  any  attention. 

There  are  many  cases  of  mixed  headache,  happening  to  young  persons  of 
both  sexes,  and  due  as  much  to  cerebral  hypersemia  as  to  nervous  disturbance. 
The  cheeks  are  flushed,  the  eyes  suffused,  and  the  patient  is  compelled  to  lie 
down  and  discontinue  the  duties  of  the  day.  The  symptoms  cannot  be 
attributed  to  a  gastric  origin,  for  the  tongue  is  clean,  the  pulse  is  quiet,  and 
there  is  no  indigestion.  Here  the  vasomotor  system  is  at  fault,  and  the 
cerebral  vessels  are  relaxed.  Remedies  like  strychnia  and  gentian,  the 
mineral  acids,  and  iron  (Form.  47-53),  ^^'^  more  serviceable  than  depletion, 
which,  by  weakening  the  nerve-force,  would  further  increase  the  excitability 
of  the  cerebral  tissue.  A  careful  discrimination  of  these  cases,  which  may 
well  baffle  a  shrewd  observer,  is  very  necessary,  and  successful  treatment 
depends  on  a  correct  diagnosis. 

As  regards  treatment,  a  mercurial  pill  followed  by  an  effervescing  aperient 
saline,  will  often  cut  short  the  attack  (Form.  18-81-61).  Three  grains  of 
blue  pill  when  the  headache  is  threatening  will  sometimes  get  rid  of  the 
misery  in  a  few  hours,  and  the  fixed  alkalies,  as  bicarbonate  of  soda  or 
bicarbonate  of  potash,  will  also  be  of  service,  by  relieving  the  acidity  of  the 
bowels.  It  is  a  good  plan  to  get  the  bowels  to  act  promptly,  and  this  may 
be  promoted  by  soap  and  water  enemata.  Where  there  is  much  throbbing 
of  the  temporal  arteries,  and  the  patient  feels  nausea  on  turning  round,  or 
going  into  a  warm  room,  an  emetic  of  ipecacuanha  or  sulphate  of  zinc 
(Form.  108-109)  will  act  in  a  marvellous  manner ;  and  even  if  there  is 
no  food  in  the  stomach  whatever,  the  effort  of  vomiting  relieves  the  conges- 
tion of  the  liver  and  duodenum,  and  the  headache  departs.  In  this  class  of 
cases,  where  there  is  hot  burning  headache,  with  cold  hands  and  feet, 
depressants  of  the  circulation  are  valuable  remedies,  and  among  them  aconite 
(Form.  106)  may  be  selected,  from  its  power  in  dilating  the  contracted 
vessels  of  the  extremities. 

During  the  acute  attacks  we  are  powerless  to  do  more  than  this,  and  when 
they  pass  away,  and  the  patient  resumes  his  ordinary  habits,  he  feels  as  well 
as  at  any  time  of  his  life.     In  cases  where  the  headache  lingers,  or  returns 


84  HEADACHES. 

from  slight  excitement  or  fatigue,  the  ordinary  treatment  would  consist  of 
bromide  of  potassium  with  laxatives  or  a  bitter  stomachic  twice  a  day  (Form. 
68),  and  if  there  is  acidity  and  flatulence,  the  subcarbonate  of  bismuth,  in 
full  doses  half  an  hour  before  meals  (Form.  107),  will  be  found  of  value.  I 
have  often  seen  great  benefit  derived  from  bromide  of  potassium  or  ammo- 
nium, with  small  doses  of  sal  volatile,  taken  on  first  getting  out  of  bed.  As 
a  sedative  at  night,  where  the  patient  rests  badly,  bromide  of  potassium 
alone  (Form.  40)  or  in  combination  with  hydrate  of  chloral,  is  the  best 
(Form.  67).  I  do  not  think  tincture  of  opium  should  be  ventured  on  in 
these  cases,  particularly  if  the  pulse  is  at  all  hard  or  incompressible  ;  but 
where  it  is  soft,  and  of  average  frequency,  I  have  known  a  few  drops  of  ne- 
phene  (Form.  69),  given  with  bromide  of  potassium  or  hydrate  of  chloral, 
tranquillize  the  patient  and  promote  refreshing  sleep.  As  long  as  the  head- 
ache persists,  a  non-nitrogenous  diet  and  abstinence  from  stimulants  ought 
to  be  observed. 

I  know  an  unmarried  lady,  thirty  years  of  age,  who  thinks  she  would  lose 
her  senses  if  she  did  not  take  a  full  dose  of  chloral  (Form.  70)  when  the 
headache  is  severe.  It  relieves  the  pain  quickly,  and  on  comparing  this  case 
with  that  of  a  patient  (much  her  senior  in  years)  who  gets  relief  from  the 
hypodermic  injection  of  morphia,  I  find  the  effects  of  the  two  agents  very- 
similar  in  the  comfort  and  undisturbed  sleep  that  ensue.  But  the  two  head- 
aches are  due  to  different  pathological  conditions — in  the  one  the  maddening 
pain  is  as  much  owing  to  increased  vascularity  of  the  contents  of  the  ence- 
phalon  as  to  a  morbid  excitability  of  the  nerve-centres ;  in  the  other  the 
nervous  system  is  primarily  and  chiefly  at  fault,  and  hydrate  of  chloral  would 
further  rob  the  brain  of  its  defective  blood-supply.  The  action  of  chloral  is 
not  always  to  be  explained  in  these  complicated  cases.  A  young  person 
who  enjoys  good  health  in  the  intervals  of  the  attacks  of  headache,  suffers  no 
continued  inconvenience  from  an  occasional  dose.  The  system  soon  rallies 
from  any  depression  it  might  induce,  but  persons  should  be  warned  not  to 
fly  too  frequently  to  this  nerve-depressant,  nor  to  take  it  at  random  without 
any  regard  to  preventive  treatment  in  the  intervals  of  suffering.  Chloral  is 
taken  for  all  kinds  of  headache  by  many,  who  get  relief  in  the  stupor  and 
drowsiness  which  follow;  and  although  they  may  resort  to  it  from  time  to 
time,  without  experiencing  any  immediate  ill  eft'ects,  they  are  nevertheless, 
in  many  cases,  injuring  their  nervous  tissue  where  it  is  frequently  resorted 
to.  The  action  of  chloral  is  double  :  in  the  first  place,  it  acts  directly  upon 
the  nerve-tissues  themselves,  lowering  their  activity ;  in  the  second  place,  it 
depresses  the  circulation  and  the  respiration.  Chloral  kills  by  paralyzing 
the  respiration  and  the  circulation  (H.  C.  Wood).  In  non-lethal  doses, 
chloral  by  its  double  action  produces  chronic  starvation  of  the  brain-tissues  ; 
not  only  that,  but  there  is  danger  in  its  continued  use,  as  not  rarely,  under 
these  circumstances,  a  fatal  result  has  followed  from  depression  of  the  circu- 
lation and  respiration  produced  by  the  ordinary  doses.  The  condition  of 
the  brain  becomes  more  and  more  debilitated  under  frequent  resort  to  it, 
and  the  excitement  gives  place  to  a  state  of  mental  lethargy  and  inaptitude, 
accompanied  by  irritability,  which  lays  the  foundation  of  perverted  nutri- 
tion, and  such  changes  in  the  nerve-centres  as  in  the  long  run  encourage 
serous  effusion,  and  the  waste  of  brain-structure.  In  those  cases  where 
chloral  furnishes  great  relief  during  the  acute  attack,  it  is  well  to  give  nerv- 
ine tonics  during  the  intervals  by  means  of  quinine,  stiychnia,  phosphorus, 
and  iron  (Form.  14-21-24);  taken  regularly  at  these  times,  the  nutrition  of 
the  brain-tissues  is  improved  and  the  attacks  are  rendered  less  frequent  and 
less  severe.  Such  treatment  duting  the  inter\'al  is  in  no  way  incompatible 
with  the  use  of  chloral  during  the  acute  attack. 


CHAPTER  IX. 

TOXEMIC    HEADACHE. 

Headache  of  Fever  OAving  to  the  Action  of  Poisoned  Blood  on  the  Nerve-centres — Character 
of  Headache  in  Acute  Fevers — Relapsing — Typhus — Simple  Continued — Enteric — 
Whooping-  cough — Measles — Scarlet  Fever — Variola — Malarial  Poisoning — Ursemic  Head- 
ache— Headache  from  Gas-poisoning — Symptoms  and  Treatment — "  Body-snatchers' 
Headache" — Local  Abstraction  of  Blood — Leeches — Cold  Affusion  to  the  Scalp — Ice-cap 
—Quinine — Ammonia — Antimony — Opium — Case  of  Headache  from  Malarial  Poisoning 
— Arsenic  and  its  Constitutional  Effects  in  continued  Doses — Phosphorus — Cod-liver  Oil. 

It  will  be  well  in  the  first  place  to  consider  under  this  category  the  head- 
ache of  fever,  which  I  have  elsewhere  termed  febrile  headache.'''  The  pain 
is  attributable  to  an  alteration  in  the  constitution  of  the  blood  and  its  com- 
ponent parts ;  this  causes  a  morbid  sensibility  of  the  nerve-centres,  and 
induces  congestion  of  the  vessels  and  membranes  of  the  brain.  When  the 
absorption  of  the  fever  poison  into  the  system  has  taken  place,  every  tissue 
through  which  the  blood  passes  is  impressed  by  it,  and  one  of  the  most  con- 
stant indications  of  its  pernicious  effects  is  headache.  Headache  is  present  in 
the  simple  fever  of  common  catarrh,  when  the  frontal  sinuses  are  congested, 
and  the  lachrymal  glands  pour  out  an  abundant  secretion.  It  is  a  strik- 
ing symptom  in  influenza  and  frequently  recurring  colds,  when  there  is 
prostration  of  the  strength,  and  the  nervous  power  is  reduced.  The  sudden 
impression  of  cold  or  atmospheric  poison  may  exert  an  influence  on  the  fifth 
nerve,  at  its  origin  in  the  brain,  through  the  branches  of  the  ophthalmic 
nerve,  springing  from  the  Gasserian  ganglion.  In  the  chapter  on  Sympathe- 
tic Headache,  I  have  already  alluded  to  this  extensive  nerve  communication, 
along  which  morbid  impressions  are  so  readily  conveyed. 

In  acute  fevers  headache  is  rarely  absent.  With  respect  to  its  relative 
freqency.  Dr.  Murcliison  has  noted  that,  of  ninety-two  cases  of  typhus, 
headache  was  complained  of  in  all  but  six.  Dr.  Henderson  found  it  in  150 
out  of  159,  and  Dr.  Stewart  in  a  large  number  of  cases. f  The  pain  gener- 
ally occupies  the  forehead  and  temples ;  it  is  of  a  dull  heavy  character,  and 
is  attended  with  giddiness  and  confusion  of  ideas.  In  young  and  strong 
children  the  pain  is  intense,  and  frequently  forms  the  most  prominent  and 
leading  feature  of  the  disease.  When  it  is  acute  and  distressing,  it  is  often 
associated  with  great  restlessness,  flushing  of  the  countenance,  and  injection 
of  the  conjunctival  vessels.  If  this  state  is  overlooked  or  neglected,  it  may 
lead  to  delirium  and  profound  somnolence,  from  which  the  patient  cannot 
be  roused. 

In  relapsing  fever,  headache  is  a  common  and  early  symptom,  and  is  more 
darting  and  throbbing  than  in  typhus. ;{;  In  typhoid  fever,  headache  is  also 
a  frequent  symptom,  both  in  adults  and  children.  Dr.  Murchison  ascer- 
tained that  it  existed  in  seventy-seven  out  of  eighty-two  cases,  and  M.  Louis 
in  all  but  seven  out  of  133  cases.  ||  The  pain  resembles  the  headache  of 
typhus  in  its  dull  continuous  character,  and  in  its  usual  limitation  to  the 

*  See  Diseases  of  Children,  and  Chapter  XVI.     Philadelphia,  Blakiston. 
f  Murchison,  On  Continued  Fevers,  1862,  p.  150. 
J  Murchison,  On  Fever,  1862,  p.  345. 
II  Ibid.,  p.  487. 

(85) 


86  HEADACHES. 

forehead ;  but  the  mental  faculties  are  rarely  impaired,  and  delirium  is  ex- 
ceptional. In  simple  continued  fever,  and  that  variety  known  as  ephemera, 
headache  is  more  or  less  present ;  and  in  some  forms  of  the  same  disease, 
where  the  duration  of  the  fever  is  longer  and  more  intense,  it  is  relatively 
more  acute  than  in  either  typhus  or  enteric  fever.*  The  poison  of  malaria 
gives  rise  to  a  severe  type  of  headache,  either  anteriorly  (frontal),  poster- 
iorly (occipital),  or  on  either  side  (hemicrania).  We  meet  with  headache, 
again,  in  whooping-cough  and  scarlatina,  in  variola,  measles,  etc.  ;  in  fact, 
in  all  those  diseases  in  which  a  toxaemic  condition  of  the  blood  exists. 
Headache  is  also  frequently  found  in  some  acute  local  inflammations,  as 
pneumonia  and  pericarditis,  and  the  treatment  should  be  determined  by 
these  respective  lesions. 

There  is  no  specific  febrile  or  inflammatory  disorder  which  does  not 
create  some  morbid  impression  on  the  brain,  and  in  many  instances,  as  we 
have  seen,  the  cerebral  cells  become  irritated  and  disturbed,  till  the  inflam- 
matory aff"ection  passes  away."]" 

I  might  reasonably  have  included  the  headaches  of  gout,  rheumatism,  and 
syphilis  under  this  name,  seeing  that  the  accumulation  of  morbid  products 

*  Murchison,  On  Fever,  1862,  p.  600. 

f  It  does  not  appear  that  the  intensity  of  the  cerebral  symptoms  in  typhoid  fever  in  adults, 
or  in  extreme  cerebral  congestion  and  tubercular  menmgitis  in  children,  bear  any  relation  to 
the  morbid  appearances  found  after  death.  In  some  fatal  cases,  when  the  head  symptoms 
have  been  trivial,  extreme  vascularity  of  the  membranes  has  been  discovered,  and  the  ves- 
sels and  sinuses  of  the  brain  have  been  gorged  with  dark  blood  ;  whilst  in  other  cases,  when 
the  head  symptoms  have  been  severe,  and  there  has  been  delirum  and  even  convulsions  in 
children,  no  sign  of  inflammation  could  be  detected,  but  considerable  effusion  of  serous 
fluid  into  the  lateral  ventricles  and  beneath  the  arachnoid.  A  large  quantity  of  intracranial 
fluid  is  not  infrequent  in  typhoid,  and  as  regards  the  substance  of  the  brain  itself  it  is  more 
frequently  found  normal  than  otherwise.  In  typhus  fever  the  same  rule  obtains,  viz.,  that 
in  the  absence  of  severe  cerebral  symptoms  during  life,  abnormal  vascularity  of  the  mem- 
branes of  the  brain  may  be  detected  after  death.  In  both  these  diseases  the  cerebral  con- 
gestion is  not  greater  than  may  be  found  to  exist  in  cases  of  severe  pneumonia  or  bronchitis, 
or  any  disease  which  has  impeded  the  pulmonary  circulation.  There  is  no  sign  of  inflam- 
mation, and  the  congestion  is  of  a  passive  rather  than  of  an  active  character.  The  transpar- 
ent and  often  colorless  serum  which  is  found  in  the  ventricles,  and  beneath  the  arachnoid,  is 
ratlier  more  common  among  the  morbid  appearances  in  typhus  than  it  is  in  typhoid.  A  few 
albuminous  flakes  are  occasionally  present  in  both  diseases,  but  there  is  no  genuine  lymph 
or  exudation  corpuscles  in  either— no  products  we  can  term  inliammatory.  The  subarach- 
noidean  serosity  and  the  fluid  between  the  convolutions  and  the  sulci  are  well  marked,  and 
this  large  amount  of  fluid,  although  not  indicating  any  inflammation,  does  assist  in  explain- 
ing the  severity  of  the  cerebral  symptoms  during  life.  In  young  children  of  rickety  constitu- 
tion, w'hen  the  head  is  growing  unusually  large,  the  convulsions  and  comatose  condition 
have,  in  my  experience,  borne  a  close  relation  to  this  excessive  secretion  of  fluid.  Yet  most 
physicians  will  declare  that  when  the  amount  of  fluid  is  trifling,  the  cerebral  symptoms  are 
as  great  as  when  the  quantity  is  excessive.  The  symptoms  are  chiefly  attributable  to  the 
altered  quality  of  the  blood,  and  the  elevatoin  of  its  temperature  in  the  cerebral  vessels.  In 
relapsing  fever  the  same  remarks  apply  without  exception ;  there  is  no  constant  relation  be- 
tween the  cerebral  symptoms  and  the  state  of  the  brain  and  its  vessels.  The  vascularity  of 
the  membranes  and  the  serosity  in  the  ventricles  do  not  in  any  way  explain  the  head  symp- 
toms during  life,  and  there  is  no  proof  whatever  that  the  brain  or  its  membranes  are  liable 
to  be  inflamed  in  consequence  of  the  fever  process.  The  inference  is  that  the  headache  of 
fever  is  essentially  dependent  on  the  presence  of  the  specific  poison  in  the  blood,  and  the 
accumulation  in  it  also  of  the  products  of  tissue  change,  which  are  not  eliminated  by  the 
proper  channels.  The  nutrition  of  the  brain  suffers  in  consequence  of  this  detention,  not- 
withstanding the  wide  difference  in  the  nature  of  the  respective  fever  poisons.  Hence  it  is 
that  the  nervous  system  generally  becomes  oppressed,  and  the  sympathetic  partially  para- 
lyzed. 

As  a  matter  of  clinical  experience,  I  am  informed  by  Dr.  Broadbent  that  protracted  head- 
ache in  the  early  stages  of  enteric  fever  denotes  unusually  severe  affection  of  Peyer's  patches, 
and  is  often  followed  by  hsemorrhage  at  a  later  period. 


TOXEMIC    HEADACHE.  8/ 

in  the  blood  impairs  the  nutrition  of  the  nervous  tissue,  and  originates  pain 
and  suffering;  but  although  these  headaches  are  sympathetic,  and  secondary 
to  the  constitutional  state  which  calls  them  forth,  I  think  a  separate 
classification  is  advisable  for  the  varieties  depending  on  the  special  affections 
to  which  I  have  alluded. 

A  form  of  headache  due  to  toxsemic  change  {tir(zmic  headache)  now  and 
then  occurs  in  connection  with  disease  of  the  kidneys,  when  their  secreting 
tissues  are  impaired,  and  they  are  no  longer  able  to  separate  the  excremen- 
titious  matters  from  the  blood.  They  may  act  energetically  for  a  time,  but 
at  length  the  morbid  material  in  the  blood  ceases  to  exert  a  diuretic  in- 
fluence, and  degeneration  in  their  structure  takes  place.  In  a  little  girl, 
aged  ten  years,  who  came  under  my  care  in  1875  with  acute  desquamative 
nephritis,  and  anasarca,  the  headache  was  most  inveterate,  occupying  the 
entire  forehead,  and  continuing  for  days  together.  When  the  local  con- 
gestion had  subsided,  and  the  urinary  secretion  had  increased  in  quantity, 
she  obtained  relief;  but  if  any  animal  food  was  taken,  even  in  the  shape  of 
beef  tea,  it  renewed  the  headache  by  still  further  impairing  the  functions  of 
the  eliminative  organs,  and  causing  on  two  or  three  occasions  severe 
h^ematuria.  Active  aperients  from  time  to  time,  and  a  diet  consisting 
exclusively  of  milk,  were  the  chief  remedies  trusted  to.  In  the  case  of  a 
man,  64  years  of  age,  who  came  under  my  care  in  1864  with  chronic  Bright's 
disease,  the  frontal  headache  was  insupportable,  and  lasted,  without  inter- 
mission, from  the  day  of  its  commencement  to  his  death,  a  period  of  many 
months.  The  slow  accumulation  of  urea  in  the  blood  (uraemic  poisoning), 
from  gradual  degeneration  in  the  kidneys,  rendered  all  attempts  at  relief 
abortive.  The  most  restricted  and  careful  diet,  with  purgatives  and  stimu- 
lating diaphoretics,  only  produced  temporary  benefit.  Where  the  cause 
cannot  be  removed,  there  is  little  to  be  gained  from  any  plan  of  treatment. 
When  he  became  anaemic,  a  few  drops  of  the  tincture  of  the  perchloride  of 
iron  were  tried ;  but  no  relief  was  obtained,  because  the  blood  became  more 
and  more  contaminated,  in  consequence  of  the  increasing  destruction  in  the 
secreting  apparatus  of  the  kidney  and  the  absorption  of  the  urinary  in- 
gredients. As  usually  happens  in  these  cases,  drowsiness  and  stupor  came 
on,  and  the  patient  died  comatose  from  uraemic  poisoning. 

The  headache  may  be  the  first  sign  that  the  kidneys  are  damaged,  and  the 
indications  are  tO'  remove  the  excessive  amount  of  urea  from  the  system. 
Put  the  patient  on  a  milk  diet,  and  give  no  animal  food  or  stimulants  of  any 
kind  whatever,  or  the  congestion  of  the  kidneys  will  increase,  and  blood 
appear  in  the  urine.  The  action  of  the  kidneys  will  be  promoted  by  giving 
acetate  or  citrate  of  potash  and  digitalis  (Form.  1-2),  or  the  same  salt  with 
spirit  of  juniper  and  decoction  of  broom.  Cream  of  tartar  drink  (tartrate  of 
potash.  Form.  3)  will  mildly  excite  the  action  of  the  renal  organs,  as  well  as 
freely  open  the  bowels,  and  unload  any  obstruction  of  the  portal  system. 
Diaphoretics,  hot-air  baths,  etc.,  are  useful  at  the  proper  time,  by  assisting 
the  elimination  of  urea  through  the  skin.  If  the  headache  is  severe,  and 
there  are  convulsions,  with  a  scanty  discharge  of  concentrated  urine,  vene- 
section or  cupping  over  the  loins  may  be  demanded  to  save  the  patient's 
life.  If  anasarca  comes  on,  and  there  are  indications  of  cerebral  oedema  or 
effusion  into  the  ventricles,  then  the  digitalis  and  citrate  of  potash  mixture 
will  be  required  to  rouse  the  flagging  action  of  the  heart  and  kidneys. 
Where  anaemia  has  been  complicated  with  the  anasarca  at  this  stage,  and  the 
blood  gets  gradually  thinner  and  more  impoverished,  I  have  found  minute 
doses  of  the  bichloride  of  mercury,  with  the  tincture  of  perchloride  of  iron, 
of  great  service  (Form.    4).     It  relieves  renal  congestion  by  favoring  the 


88  HEADACHES. 

escape  of  exudative  products  from  the  urinary  tubules,  and  in  this  way  it  in- 
creases the  diuretic  action  of  the  kidneys,  and  improves  the  vitiated  state  of 
the  blood  at  the  same  time.  Under  this  treatment  I  have  witnessed  every 
trace  of  anasarca  disappear,  and  the  headache  depart  entirely. 

I  cannot  dismiss  this  character  of  headache  without  considering  the  effect 
which  toxic  agents  have  on  the  blood  and  nervous  system,  when  the  atmos- 
phere is  vitiated  by  crowded  assemblies  or  the  imperfect  ventilation  of  apart- 
ments. I  believe  that  the  accumulation  of  carbonic  acid  and  expired  air  in 
school  and  lecture  rooms  is  to  be  reckoned  among  the  chief  exciting  causes  of 
headache  in  young  persons,  and  still  more  in  adults,  when  the  nervous  system 
becomes  more  susceptible  with  the  advance  of  years. 

"The  normal  quantity  of  carbonic  acid  being  .4  volumes  per  1000,  it  pro- 
duces fatal  results  when  the  amount  reaches  from  50  to  100  per  1000  volu- 
mes; and,  at  an  amount  much  below  this,  15  or  20  per  1000,  it  produces 
in  some  persons,  at  any  rate,  severe  headache.  Other  persons  can  inhale, 
for  a  brief  period,  considerable  quantities  of  carbonic  acid  without  injury; 
and  animals  can  be  kept  for  a  long  time  in  an  atmosphere  highly  charged 
with  it,  provided  the  amount  of  oxygen  be  also  increased.  In  the  air  of 
respiration,  headache  and  vertigo  are  produced  when  the  amount  of  car- 
bonic acid  is  not  more  than  1.5  to  3  volumes  per  1000;  but  then  organic 
matters,  and  possibly  other  gases,  are  present  in  the  air,  and  the  amount 
of  oxygen  is  also  lessened.  Well-sinkers,  when  not  actually  disabled  from 
continuing  their  work  by  carbonic  acid,  are  often  affected  by  headache, 
sickness,  and  loss  of  appetite,  but  the  amount  of  carbonic  acid  has  never 
been  determined."* 

Facts  like  these  attest  the  danger  of  continually  breathing  an  atmosphere 
vitiated  and  overcharged  with  carbonic  acid.  The  dangerous  consequences 
are  first  made  manifest  in  the  reduction  of  the  force  and  frequency  of  the 
heart's  action, f  and  in  the  enfeeblement  of  the  whole  capillary  circulation, 
which  causes  the  brain  gradually  to  become  exhausted  from  the  diminished 
quantity  of  blood  it  receives,  and  then  follow  headache,  languor,  and  inca- 
pacity for  sustained  mental  exertion. 

When  the  amount  of  carbonic  acid  in  the  atmosphere  is  large,  the  requi- 
site elimination  of  it  from  the  lungs  does  not  take  place,  and  the  blood,  be- 
coming more  venous  and  impure,  fails  to  impart  its  accustomed  stimulus  to 
the  cerebral  vessels,  which  now  fall  into  an  atonic  state ;  while  the  normal 
amount  of  oxygen  in  the  blood  is  replaced  by  the  retention  of  the  gas,  and  a 
diminution  of  vascular  pressure. 

In  one  form  of  headache  the  symptoms  appear  to  have  arisen  from  gas-pois- 
oning, i.  e.,  gas  generated  by  putrefaction,  fecal  fermentation  absorbed  into 
the  blood,  and  thus  producing  its  effects  upon  the  brain  and  spinal  cord. 

This  form  of  headache  often  commences  with  a  feeling  of  heaviness  and 
dullnes  the  first  thing  in  the  morning,  and  gradually  increases  till  the  middle 
of  the  day,  when  it  may  be  temporarily  relieved  by  luncheon ;  but  it  soon 
reappears  and  increases  through  the  afternoon  and  evening,  unless  relieved 
by  treatment. 

Li  the  head  there  is  a  sense  of  heat,  weight,  and  dullness,  and  nervous 
prostration,  and  inability  to  apply  the  mind  to  work,  or  to  make  any  physi- 
cal exertion — -the  legs  seem  to  lose  their  power  more  or  less. 

The  tongue  may  be  quite  clean,  or  have  a  little  white  coating;  but  it  never 

.    *  Practical  Hygiene,  by  Dr.  Parkes,  1873,  4th  edition,  Philadelphia,  Blakiston,  p.  112. 

■j-  Cyon  brought  a  frog's  heart  to  a  standstill  by  passing  through  it  serum  charged  with 
carbonic  acid  ;  on  removing  the  carbonic  acid  from  the  serum,  the  heart  began  to  beat  again. 


TOXyEMIC    HEADACHE.  89 

has  the  thick  yellow  fur  at  the  back  and  sides,  always  present  in  the  bilious 
headache. 

Treat7nent. — The  only  remedy  is  a  gastric  purge,  in  a  fluid  form  to  insure 
rapidity  of  action.  This  brings  away  a  fetid  evacuation,  with  the  escape  of 
extremely  offensive  gas,  generated  by  the  putrefactive  fermentation  which 
has  taken  place  instead  of  healthy  digestion.  Senna,  aloes,  Tamar-Indien, 
syrup  of  buckthorn,  are  amongst  the  most  useful  remedies.  Saline  aperients 
are  utterly  useless,  as  they  fail  to  bring  away  the  offensive  gas,  and  only  pro- 
duce watery  evacuations — a  little  saline  may  be  usefully  combined  with  the 
drastic,  as  quickening  its  action  and  allaying  any  feverish  condition,  but  the 
drastic  must  be  relied  upon,  and  its  effect  obtained.  Stimulants  are  de- 
cidedly injurious. 

This  form  of  headache  with  gas-poisoning  very  much  resembles  the  head- 
ache from  gas-poisoning  by  sewer-gas,  from  decomposed  bodies  in  the  dead- 
house  and  dissecting-room.  The  old  "  body-snatchers"  were  quite  familiar 
with  it. 

My  friend,  Mr.  W.  Adams,  informs  me  that  in  the  year  1842,  and  for 
some  few  years  afterwards,  when  he  used  to  make  the  post-mortem  examina- 
tions at  St.  Thomas's  Hospital,  he  had  as  a  dead-house  assistant  a  well- 
known  man  who  had  been  one  of  the  leading  body-snatchers  for  many 
years,  and  he  told  him  that  when  doubling  up  a  body  and  putting  it  into  a 
sack,  the  body-snatchers  always  turned  their  heads  away,  and  were  extremely 
careful  not  to  inhale  any  of  the  gas  which  generally  escaped  from  the  stom- 
ach of  the  body  when  bent.  If  a  body-snatcher  should  •'  get  a  gulp,'-'  as  he 
expressed  it,  he  knew  it  would  be  followed  by  headache  and  nervous  de- 
pression from  gas-poisoning,  and  he  had  learnt  from  experience  that  these 
symptoms  would  be  increased  by  gin  or  brandy,  to  which  he  would  naturally 
resort.  This  man  told  Mr.  Adams  that  on  these  occasions  he  always  avoided 
spirits,  and  took  two  strong  pills  as  soon  as  he  got  home.  Thus  he  had 
learned  that  the  eliminative  treatment  by  a  drastic  purge  was  the  only  relia- 
ble means  of  curing  the  headache  and  depression  produced  by  gas-poison- 

In  the  treatment  of  the  forms  of  headache  arising  from  specific  fever,  care- 
ful judgment  will  be  required.  When  the  brain  is  oppressed  by  the  high 
temperature  of  the  blood,  and  the  accumulation  of  effete  and  j^oisonous  mat- 
ters within  it,  there  is  imminent  danger  to  life,  if  this  state  of  things  is  per- 
mitted to  go  on  unchecked.  The  local  abstraction  of  blood  is  a  measure  to 
be  held  in  recollection,  seeing  that  it  has  sometimes  averted  the  most  threat- 
ening cerebral  symptoms.  It  removes  the  extreme  venous  tension,  and,  by 
promoting  a  free  action  of  the  skin,  brings  down  the  temperature.  Three 
or  four  leeches  applied  to  the  temples  will  act  in  a  most  efficacious  manner, 
and  relieve  the  patient  more  completely  and  quickly  than  any  other  remedy 
at  our  command.  Cold  affusion  to  the  scalp,  or  the  application  of  the  ice- 
cap, may,  in  ordinary  cases,  render  their  employment  unnecessary,  but  the 
abstraction  of  blood  is  sometimes  the  only  chance  of  subduing  the  pain,  and 
amending  the  patient's  general  condition.  In  the  headache  of  aged  and 
feeble  persons,  who  are  struck  down  by  fever,  warm  fomentations  appear  to 
be  of  service.  They  were  used  by  the  late  Dr.  Graves,  and  sanctioned  by 
Dr.  Murchison.*  It  must  be  understood,  however,  that  there  is  the  head- 
ache of  exhaustion  which  succeds  sleeplessness,  and  is  independent  of  any 
inflammatory  condition  of  the  brain  or  membranes.  For  this  state,  quinine, 
ammonia,  opium,  and  antimony  may  be  demanded  to  restore  the  equilibrium 

*  Loc.  cit.,  p,  274. 
6 


90  HEADACHES. 

of  the  brain,  and  to  mitigate  the  nervous  agitation  which  is  associated  with 
it. 

In  the  headache  due  to  malarial  poisoning  a  full  dose  of  quinine  will  be 
advisable,  if  it  is  periodical  in  character.  As  large  a  dose  as  gr.  x  or  gr.  xv 
has  been  recommended  before  the  attack,  and  it  may  be  necessary  to  push  it 
to  cinchonism  in  divided  doses,  and  then  gradually  diminish  the  dose. 
(Form.  5.) 

The  following  is  a  severe  case  of  malarial  poisoning  and  hemicrania  : 

J.  R.,  ^t.  49,  m.,  sallow,  tall,  and  corpulent,  consulted  me  July  3d,  1877. 
Has  lived  in  Bombay  for  twenty-five  years,  and  had  good  health  till  nine 
years  ago  (186S),  when  he  got  headache  diffused  over  the  forehead.  Two 
daj^s  later,  he  had  a  bilious  attack — violent  spasms,  retching  and  bringing 
up  large  quantities  of  bile,  passing  it  by  the  bowels  as  well.  The  attacks 
came  on  once  or  twice  a  Aveek,  and  the  doctors  ascribed  them  to  malaria. 
There  were  new  drainage  works  going  on,  v/hich  his  duties  called  upon  him 
to  superintend.  After  suffering  more  or  less  for  fourteen  months  he  went  to 
Australia,  and  there  lost  his  headache ;  but  on  his  return  to  Bombay  he  suf- 
fered again,  within  six  or  eight  weeks. 

In  1870  he  was  ill  again,  and,  in  consequence,  came  to  England,  and  lost 
his  bilious  attacks,  but  not  his  headache.  His  wife,  who  was  with  him  in 
India  at  the  time,  became  subject  to  similar  attacks,  and  it  is  only  recently 
that  they  have  abated  in  severity. 

In.  November,  1872,  he  returned  to  Bombay,  and  was  as  bad  as  ever; 
then  he  suffered  from  1872  to  July  1877,  and  for  some  time  took  forty-five 
grains  of  quinine  in  three  doses  daily  for  one  month  ;  the  effect  was  to  keep 
off  the  headache  for  one  year,  during  which  time  he  felt  well ;  the  urine  was 
clear,  and  the  motions  healthy.  When  the  headache  was  bad,  heat  or  cold 
applied  over  the  eye  would  give  relief;  occasionally  there  was  pain  in  the 
right  eye,  and  insupportable  depression  of  spirits  accompanied  it. 

In  1875  he  came  to  England  again  for  three  months,  and  derived  consid- 
erable benefit ;  returned  in  November,  and  after  being  a  month  in  Bombay 
the  spasms,  vomiting,  and  headache  returned  in  all  their  former  severity. 
He  took  ipecacuanha,  which  made  him  sick  and  ill ;  and  since  then  he  has 
had  no  vomiting,  but  severe  headache,  extending  through  the  left  eye  and 
temple,  which  would  find  its  escape  through  the  left  shoulder.  He  was 
worst  at  noon,  when  the  sun  was  at  its  height ;  generally  the  pain  would  be- 
gin at  3  a.  m.  and  last  until  7  p.  m.,  when  he  fell  asleep,  and  woke  up  re- 
lieved in  a  few  hours  ;  a  cup  of  tea  or  coffee  would  sometimes  relieve  the 
pain  quickly.  Heavy  sleep  and  snoring  were  invariable  precursors  of  an  at- 
tack. During  the  last  year,  his  memory,  which  was  formerly  acute,  has  be- 
come very  defective. 

There  is  no  disease  of  the  heart,  liver,  or  spleen;  abdomen  very  large  and 
flabby ;  he  is  now  fidgety  and  irritable,  and  cannot  bear  the  least  noise  or 
excitement ;  he  looks  pallid  and  sallow ;  pulse  96  ;  tongue  clean  ;  bowels 
free;  urine  clear,  reaction  acid,  sp.  gr.  1020,  non -albuminous.  He  has 
taken  tincture  of  gelseminum,  croton  chloral,  and  bromides,  without  benefit. 
He  was  now  ordered  arsenic,  quinine,  and  bromide  of  potassium  twice  a 
day  in  a  mixutre,  and  a  dose  of  Friedrichshalle  water  in  the  morning,  twice 
a  week.  The  diet  was  to  be  plain  and  simple,  with  a  little  claret  and  water 
with  his  meals;  cheese,  pastry,  and  tea  to  be  avoided. 

July  9th.  Has  had  some  headache  over  the  left  eye,  but  not  so  piercing 
or  severe ;  he  caught  cold  a  few  days  ago,  which  he  considers  a  sufficient 
cause.  The  bowels  not  having  acted  satisfactorily,  he  was  ordered  to  take 
two  "oills  of  aloes  and  myrrh,  with  half  a  grain  of  sulphate  of  iron  (Form. 
86).^ 


TOXEMIC    HEADACHE.  9 1 

July  1 2th.  He  is  much  better,  and  has  had  no  headache  since  the  last 
visit.  Two  pills  acted  well,  and  produced  two  motions;  urine  clear;  he 
feels  stronger  and  not  worried  with  anything  or  anybody;  pulse  84;  free 
from  pain  entirely.      His  aspect  is  now  clear  and  animated. 

July  17th.  On  the  15th,  i6th,  and  17th,  headache  began  at  3  and  4  a.  m., 
and  lasted  till  8  and  9  a.  m.,  each  morning.  It  commenced  over  the  entire 
brow,  forehead,  and  eyes  ;  now  it  has  extended  to  the  left  side  of  the  head, 
and  he  has  pain  and  tightness  in  the  right  side  over  the  liver.  The  pain 
makes  him  emotional ;  he  can  scarcely  avoid  crying  or  being  excited,  and 
he  often  sheds  tears  when  reading.  The  region  of  the  liver  is  tender  and  its 
area  slightly  increased  ;  the  urine  is  turbid  and  high-colored.  He  was  or- 
dered a  pill  containing  agrain  of  calomel  at  bed  time,  a  sulphate  of  magnesia 
draught  in  the  morning,  and  citrate  of  potash  with  quinine  in  an  effervescing 
mixture  during  the  day. 

July  25th.  On  the  22d  he  went  to  church,  and  there  felt  pain;  on  the 
following  day  it  recurred;  then  on  the  succeeding  evening  had  attacks  last- 
ing for  some  hours.  This  occurred  for  three  evenings,  and  on  the  23d  did 
not  get  up  till  6  p.  m.  The  pain  begins  in  the  left  eye,  and  then  extends 
over  the  head,  but  he  has  had  no  shivering;  he  sleeps  better,  and  is  cer- 
tainly improved  in  all  respects.  A  mixture  of  citrate  of  iron  and  arsenic 
was  now  ordered  to  be  taken  twice  a  day  after  food,  when  free  from  head- 
ache, and  the  bromide  mixture  when  an  attack  was  threatening  (Form.  26). 
July  30th.  His  head  had  been  better,  but  two  mornings  since  he  had 
acute  pain  over  the  liver,  sudden  and  piercing,  and  this  he  has,  experienced 
in  Bombay.  There  are  no  physical  signs  of  hepatic  congestion  ;  the  urine 
is  clear,  and  the  bowels  free.  The  iron  mixture  seems  to  exert  a  slightly 
aperient  effect. 

August  14th.  He  had  no  attack  whatever  till  the  loth,  when  it  began  in 
a  moment  at  4  p.  m.,  and  continued  all  day  and  night.  On  the  nth  the 
pain  was  better  in  the  early  morning,  then  it  returned  at  i  p.  m.  and  lasted 
all  night.  Before  the  attack  of  headache  comes  on  the  urine  is  always 
cloudy  and  thick,  and  when  it  passes  away  it  becomes  clear.  This  period- 
icity in  the  headache  suggests  the  use  of  quinine  in  large  doses,  and  there- 
fore the  previous  medicines  were  discontinued,  and  two  pills,  each  contain- 
ing three  grains  of  quinine,  were  prescribed  twice  a  day. 

September  26th.  A  month's  residence  at  the  seaside  improved  his  gen- 
eral condition,  but  he  had  three  attacks,  two  mild  and  one  severe.  He  took 
quinine  only  when  the  pain  was  on  him. 

October  6th.  On  returning  to  town  a  few  days  since  he  got  an  attack 
of  headache,  which  seized  the  forehead  at  3  a.  m.,  and  then  settling  in  the 
right  temple  and  eye,  gradually  passed  up  to  the  top  of  the  head,  where,  as 
a  heavy  weight,  it  would  last  for  hours.  I  now  gave  a  phosphorus  capsule 
(gr.  sV  daily)  and  quinine  and  iron  in  a  mixture;  in  addition,  as  the  patient 
was  corpulent,  a  Turkish  bath  was  ordered  once  in  ten  days,  and  a  dose  of 
Friedrichshalle  water  twice  a  week. 

December  nth.  The  patient  reported  himself  quite  well  in  health,  and 
his  general  appearance  and  manner  fully  bore  out  his  testimony,  for  he  was 
now  active  and  energetic,  and  most  desirous  to  return  to  his  duties  in  India. 
He  had  in  a  great  measure  exchanged  his  sallow  aspect  for  a  fresh  color, 
and  his  eyes  sparkled  with  intelligence  and  vigor ;  he  took  long  walks  with- 
out fatigue,  and  went  into  society  without  experiencing  any  after  ill  effects. 
In  February,  1878,  he  returned  to  Bombay  quite  well  in  health. 

If  the  pain  continue  to  recur  in  these  cases.  Fowler's  solution  and  tincture 
of  belladonna,  in  five-drop  doses,  are  recommended  by  Dr.  Smith,  increas- 


92  HEADACHES. 

ing  the  arsenical  solution  one  drop  each  day  (Form.  6  to  9).  It  may  be 
advisable  to  persevere  with  this  combination  if  phosphorus  and  quinine 
should  fail.  "  I  have  witnessed  the  postponement  and  ultimate  cessation  of 
a  periodic  headache,  through  the  influence  of  arsenic,  before  the  prickling 
eyelid  or  silvered  tongue  demonstrated  its  agency  "  (Begbie).  Arsenic  is  a 
remedy  of  the  greatest  possible  value  in  nervous  cases,  if  it  is  given  judi- 
ciously and  watched  carefully,  but  it  is  too  generally  abandoned  on  the  first 
symptoms  of  constitutional  irritation  becoming  manifest,  and  when  its 
alterative  effects  on  the  blood  are  about  to  be  secured.  Under  these  circum- 
stances it  should  be  suspended  for  a  time,  and  then  cautiously  resumed. 
Every  practitioner  should  make  himself  familiarly  acquainted  with  the 
physiological  signs  of  arsenical  action,  for  the  exhibition  of  small  doses  long 
together,  in  some  persons  of  peculiar  idiosyncrasy,  is  accompanied  with  so 
much  nausea  and  nervous  depression,  as  to  render  the  continuance  of  the 
remedy  inadmissible.* 

Phosphorus  is  another  good  remedy  in  nervous  and  neuralgic  headache, 
and  also  in  that  form  arising  from  the  poison  of  malaria,  as  we  have  just 
seen,  where  the  nerve-centres  are  depressed  and  exhaustion  is  the  conse- 
quence of  it.  Its  action  is  not  unlike  that  of  iron  and  cod-liver  oil,  and  it 
is  a  constituent  of  many  of  the  tissues,  especially  the  nervous.  I  have  now 
and  then  observed  its  beneficial  effects  after  the  failure  of  other  well-known 
remedies,  and  therefore,  in  all  obstinate  cases,  it  should  have  a  fair  trial,  as 
its  general  tonic  effects  in  repairing  the  waste  of  nervous  tissue  are  very 
marked,  and  in  my  experience  it  has  occasionally  produced  the  happiest  re- 
sults. 

Phosphorus  is  one  of  the  most  important  agents  we  possess  in  nervous 
exhaustion,  and  its  efficacy  is  undoubted  when  administered  in  an  unoxidized 
state,  capable  of  being  readily  assimilated.  No  remedy  requires  more  care 
in  prescribing  than  this,  for  whilst  in  small  doses  it  is  a  gentle  stimulant  and 
tonic,  in  large  doses  it  depresses  the  heart's  action  like  chloral,  and  is  not 
free  from  danger.  It  may  be  well  to  begin  with  gr.  ^l,  but  I  have  seen  no 
ill  effects  from  gr.  J^ ;  and  thus,  after  a  time,  may  be  taken  twice  a  day.  I 
never  exceed  this  quantity.  Then  as  to  the  best  mode  of  giving  it.  The 
Pil.  Phosphori  of  the  British  Pharmacopoeia  is  seldom  ordered,  as  it  is  open 
to  objections,  which  are  now  overcome  by  more  recent  modes  of  prescribing 
phosphorus  in  such  a  form  as  shall  insure  its  activity.  The  Pharmacopoeia 
pill,  when  made,  is  kept  in  water,  and  after  a  time  it  becomes  extremely 
hard,  and  resists  absorption  in  the  stomach,  passing  through  the  intestines  in 
an  unchanged  state. 

As  an  excellent  solvent  of  phosphorus,  cocoa  butter  and  Castile  soap 
have  been  recommended  {Yearbook  of  Pharmacy,  1876),  to  form  into  pills 
which  will  keep  well,  and  retain  their  properties.  Messrs.  Squire  recom- 
mend a  formula  composed  of  mutton  suet,  liquorice,  and  mastic.  They  con- 
sider it  an  excellent  combination,  as  the  virtue  of  the  phosphorus  is  retained, 
while  in  this  form  it  is  taken  up  readily  by  the  stomach. 

*  "  Arsenic,  when  given  continuously  in  moderate  doses — say,  five  drops  of  the  liquor 
arsenicalis,  diluted  largely  with  water,  twice  or  thrice  a  day — will,  sooner  or  later,  generally 
within  eight  or  ten  days,  produce  increase  of  heat  and  dryness  of  skin,  together  with  accelera- 
tion of  pulse,  followed  by  a  sense  of  heat  and  itching  of  the  eyelids,  to  which  succeed 
swelling  and  tenderness;  the  conjunctiva  becomes  inflamed,  the  eye  sensitive  to  light,  and 
the  orbits  surrounded  by  a  dark  discoloration.  The  tongue  at  this  time  will  be  found  finely 
coated  with  a  white  silveiy  film,  resembling  that  produced  by  touching  its  surface  with  a 
weak  solution  of  the  lunar  caustic.  .  .  .  The  throat  becomes  diy  and  sore,  the  gums  swollen 
and  tender;  and,  if  the  medicine  is  still  further  persisted  in,  salivation  ensues." — "  On  the 
Physiological  and  Therapeutical  Effects  of  Arsenic,"  by  James  Begbie,  M.  D.,  F.  R.  S.  E., 
in  Contributions  to  Practical  Medicine,  1862,  p.  270. 


TOXEMIC    HEADACHE.  93 

The  perles  of  phosphorus  are  an  excellent  form  for  administration.  They 
appear  to  retain  the  virtues  of  the  drug  for  an  indefinite  time,  and  to  be 
readily  digested  and  absorbed. 

This  leads  me  to  say  that  the  sugar-coated  pills  containing  phosphorus  are 
unreliable.  I  am  told,  on  good  authority,  that  the  phosphorus  is  oxidized 
or  volatilized  by  the  necessary  heat  employed  in  the  process.  If  there  is  a 
base  such  as  oxide  or  carbonate  of  iron,  or  strychnia,  it  will  form  a  chemi- 
cal combihation  and  become  a  hypophosphite.  Hypophosphites  are  made 
by  boiling  phosphorus  with  lime  or  soda. 

Cod-liver  oil,  as  in  all  forms  of  neuralgia,  is  sometimes  of  great  service  in 
hemicrania  and  neuralgic  headache,  if  the  opportunity  is  seized  of  giving  it 
in  the  intervals  of  suffering,  when  the  patient  is  free  from  pain.  As  in 
som^e  cases  of  gastralgia,  cod-liver  oil  brings  relief  when  ferruginous  tonics 
and  the  most  careful  diet  fail,  so  will  it  frequently  ward  off  attacks  of  neu- 
ralgic headache  by  improving  general  nutrition,  and  strengthening  the  tone 
of  the  nervous  system. 


CHAPTER  X. 


ARTHRITIC    OR    GOUTY    HEADACHE. 


Sometimes,  though  not  frequently,  the  Accompaniment  of  Acute  Articular  Gout — Illustrative 
Cases — Influence  of  the  Gouty  Diathesis — Affection  of  the  Brain  and  Membranes  in  Sup- 
pressed Gout — Character  of  the  Pulse  and  Heart's  Sounds — Importance  of  exciting  Action 
in  the  Eliminative  Organs — Mercurials — Podophyllin — Alkalies — Salts  of  Lithia — Car- 
bonate of  Ammonia. 

When  the  febrile  disturbance  is  considerable,  and  the  secretions  vitiated, 
acute  gout  is  now  and  then  attended  with  severe  frontal  headache,  and 
weight  across  the  eyes.  Many  persons  who  experience  periodical  attacks  of 
acute  articular  gout  escape  headache  altogether ;  but  others  are  not  so  fortu- 
nate. I  should  say  from  my  OAvn  experience  that  headache  is  not  a  frequent 
accompaniment  of  gout,  and  that,  whenever  it  is  present,  it  is  generally  in 
those  persons  whose  general  health  has  been  shaken  by  many  previous 
attacks,  and  whose  nervous  system  has  suffered  in  consequence.  One 
gentleman,  who  consulted  me  in  1867,  stated  that  for  upwards  of  twenty 
years  he  had  been  a  martyr  to  gout,  but  that  the  last  attacks  had  alarmed 
him  from  the  severe  headache  which  accompanied  them,  although  the  foot 
was  swelled  and  inflamed,  and  the  urine  copious  and  free  from  albumen. 
The  pain  was  frontal,  obstinate,  and  depressing,  and  it  continued  for  some 
days  after  the  local  inflammation  had  subsided.  Carbonate  of  ammonia 
proved  a  reliable  remedy;  and  sometimes  a  stimulating  draught,  consisting 
of  quinine,  chloric  ether,  and  camphor,  was  of  great  use  in  relieving  the 
pain  (Form.  16-30). 

A  gentleman,  thirty-five  years  of  age,  who  was  suff"ering  from  his  fifteenth 
attack  of  acute  gout  in  May,  1876,  consulted  me  for  headache,  which  was  a 
new  symptom  of  his  conriplaint.  The  right  great  toe  was  vividly  inflamed 
and  tender,  and  had  been  so  for  some  days  before  I  saw  him.  His  nights 
were  disturbed  and  restless  (as  they  had  been  on  many  former  occasions), 
but  he  was  reluctant  to  attribute  the  headache  to  pain  in  the  joint,  or  to 
want  of  sleep.  As  the  urine  was  abundant  and  clear,  and  the  bowels 
thoroughly  open,  I  attributed  the  headache  to  the  local  pain  and  general 
weakness;  and  I  prescribed  the  carbonates  of  ammonia  and  potash  in 
effervescence,  with  small  doses  of  colchicum.  Under  this  treatment  the 
local  disorder  soon  subsided,  and  the  headache  departed. 

Dr.  Garrod  mentions  a  very  interesting  case  of  gouty  headache  in  a  lady, 
sixty  years  of  age,  who  consulted  him  for  intense  headache,  from  which  she 
had  suffered  about  seventeen  days.  The  pain  chiefly  occupied  the  vertex 
and  back  of  the  head,  and  was  somewhat  periodic  in  character.  There  was 
heat  and  tenderness  of  the  painful  part.  The  affection  was  considered 
hysterical  at  first,  but  on  the  next  evening  the  pain  suddenly  left  the  head, 
and  the  ball  of  the  great  toe  became  acutely  painful  and  tender,  swollen, 
red,  and  shining.  It  was  a  severe  attack  of  acute  gout.  The  occurrence  of 
a  second  fit  after  some  months  was  not  preceded  by  headache.* 

The  influence  of  the  gouty  diathesis  in  exciting  severe  headache  is  well 

■^On  Gout  and  Rheumatic  Gout,  by  A.  B.  GaiTod,  M.  D.,  F,  R.  S.,  1862,  p.  515. 

(94) 


ARTHRITIC    OR    GOUTY    HEADACHE.  95 

illustrated  in  the  following  case  recorded  by  Dr.  Begbie.*  For  the  limita- 
tion of  space  at  my  disposal,  I  shall  make  no  apology  for  abridging  the 
details.  A  lady,  aged  thirty-five,  of  full  habit  and  florid  complexion,  had 
suffered  for  many  years  from  severe  and  lasting  headache,  which  had  defied 
the  power  of  many  and  divers  remedies.  It  was  difficult  to  fix  upon  any 
variety  of  headache  which  had  been  observed  to  answer  to  the  character  of 
that  which  she  presented.  "It  was  not  nervous  or  hysteric;  it  was  not 
inflammatory  or  congestive ;  it  was  not  anemic ;  it  was  not  dyspeptic.  It 
could  not  be  traced  to  cerebral  disease;  it  was  not  of  neuralgic  or  rheumatic 
character ;  it  was  not  periostitic ;  it  was  not  periodic.  As  the  urinary  secre- 
tion from  time  to  time  presented  alternately  oxalates  and  lithates  in  great 
excess,  and  the  hands  of  the  patient's  father  presented  'the  little  knobs  of 
Heberden,'  some  light  at  length  arose  to  reveal  the  true  character  of  the  per- 
plexing headache.  The  paternal  grandfather  was  the  victim  of  gout,  and 
died  of  heart  disease.  Under  the  persistent  employment  of  a  combination 
of  colchicum  with  the  nitrate  and  carbonate  of  potash,  aided  by  those  regu- 
lations of  diet  and  exercise  which  are  suitable  to  the  gouty  habit,  the  severe 
headaches  were  relieved  and  ultimately  removed." 

There  is  another  form  of  headache  occurring  to  persons  subject  to  irregular 
gout,  and  who  are  sallow  and  cachectic  in  appearance.  This  form  is  far 
more  important  than  the  varieties  we  have  been  considering,  because  it 
denotes  a  more  serious  affection  of  the  brain  or  membranes  by  the  gouty 
poison,  due  to  the  latter  not  finding  its  proper  vent  through  the  joints  and 
cutaneous  surface.  Some  years  ago  I  attended  a  gentleman  who  suffered 
from  this  form  of  headache.  He  was  nearly  sixty  years  of  age  when  he  first 
came  under  treatment,  and  remained  under  my  observation  for  upwards  of 
twelve  years.  The  character  of  the  urine  and  evacuations  from  the  bowels 
indicated  great  disorder  in  the  functions  of  digestion  and  assimilation ;  and, 
although  there  were  pains  and  obscure  swellings  in  the  knuckles,  wrist,  and 
feet,  no  regular  attack  of  gout  ever  showed  itself.  The  symptoms  were  due 
to  the  retention  of  the  gouty  poison.  The  patient  was  liable  to  be  seized 
with  giddiness  in  walking,  and  could  only  be  saved  from  falling  by  being 
supported.  He  experienced  at  the  same  time  noises  in  the  ears,  and  a  sen- 
sation as  of  something  giving  way  in  the  head.  His  complexion  was  sallow, 
his  sight  dim,  his  face  bedewed  with  perspiration,  and  his  pulse  weak  and 
slow.  His  tongue  was  generally  clean,  or  only  very  slightly  furred;  while 
the  motions   were    always   either  clay-colored    or  dark   and   bilious,   and 

*  On  Gout  and  the  Gouty  Diathesis,  in  Contributions  to  Practical  Medicine,  1862,  p.  29, 
case  xvi. 

"  It  is  somewhat  difficult  to  class  the  several  forms  of  intermittent  headache  with  other 
affections  of  this  kind ;  but  those  having  lengthened  periods  of  intermission  may  best  per- 
haps be  noted  liere.  The  equality  of  time  often  observed,  even  where  the  intervals  extend 
to  two  or  three  weeks,  or  yet  longer,  is  a  very  remarkable  feature  in  these  cases,  and  denotes 
a  cause  specific  in  its  nature  and  uniform  in  its  operation.  I  know  instances  where  such 
intermittent  headaches  have  occurred  during  the  greater  part  of  a  protracted  life.  !More 
frequently,  however,  it  happens  that  they  affect  especially  certain  periods  of  life ;  in  this,  as 
in  many  other  circumstances,  showing  singular  relation  to  the  disordered  actions  of  the  gouty 
constitution,  with  which,  as  I  have  stated  in  a  former  chapter,  1  cannot  doubt  their  close 
kindred  and  dependence  on  the  same  causes.  In  conformity  with  this  view  there  is  reason 
to  believe  that  the  kidneys  are  the  excretory  organs  most  concerned  in  giving  relief  in  these 
cases,  and  principally  by  an  increased  separation  of  the  lithic  acid  or  its  compounds.  Such 
action  may  readily  escape  notice,  where  the  attention  is  directed  by  the  presence  of  pain  to 
another  part ;  but  I  infer  it  from  close  observation  of  many  intermittent  headaches,  and  think 
the  remark  likely  to  be  confirmed  by  others." — "On  Morbid  Actions  of  an  Intermittent 
Kind,"  in  Medical  Notes  and  Reflections,  by  Sir  H.  Holland,  Bart.,  M.  D.,  F.  R.  S.,  1855, 
p.  288. 


96  HEADACHES. 

the  urine  threw  down  a  thick  reddish  sediment.  It  was  noticeable  that  the 
headache  was  often  relieved  when  the  urinary  secretion  became  thus  changed. 
An  active  mercurial  medicine  would  generally,  I  found,  relieve  the  headache 
after  the  secretions  were  rectified ;  but  occasionally  the  symptoms  would  con- 
tinue for  days,  accompanied  with  extreme  flatulence,  disordered  digestion, 
and  irritability  of  temper.  On  some  occasions  there  were  fearful  attacks  of 
painful  colic ;  but  vv^hen  these  were  present  the  head  was  free  from  dis- 
comfort. 

When  effete  products  accumulate  in  the  blood,  the  vasomotor  centre 
becomes  damaged,  and  the  minute  arterioles  are  thrown  into  a  state  of  spas- 
modic contraction.  This  is  proved  by  the  increased  tension  in  the  pulse, 
and  the  reduplicate  and  accentuated  sounds  of  the  heart,  as  in  the  case  of 
albuminuria.  In  the  confirmed  gouty  headache  of  advancing  years  the  cere- 
bral arteries  are  atheromatous  and  thickened,  and  the  calibre  being  dimin- 
ished, the  blood-supply  to  the  brain  is  insufficient  to  nourish  it.  The  emo- 
tional conditions  to  which  this  important  change  gives  rise  are  shown  in 
outbursts  of  passion,  and  fits  of  melancholy  depression.  "Irascibility  is 
the  characteristic  par  excellence  of  a  brain  fed  with  blood  laden  with  gout- 
poison,  and  hastiness  is  habitual ;  but  as  the  condition  of  heart-failure  be- 
comes slowly  developed  and  superimposed  upon  the  gouty  condition,  the 
characteristics  of  cerebral  anemia  are  blended  with  those  of  lithiasis."* 

For  this  variety  of  gouty  headache,  absolute  repose,  light  diet,  and  careful 
attention  to  the  liver  and  bowels,  are  of  paramount  importance.  If  the 
kidneys  are  structurally  unsound,  the  patient  is  in  constant  danger  of  his 
life  from  the  accumulation  of  the  gouty  poison  ;  but  if  they  act  well,  relief 
may  be  obtained.  This  headache,  in  fact,  is  due  to  gout  pent  up  in  the  sys- 
tem, and  damaging  the  nervous  centres,  instead  of  seeking  elimination 
through  the  joints  in  the  form  of  articular  inflammation.  The  treatment, 
therefore,  is  much  the  same  as  for  gout,  modified  according  to  the  peculiari- 
ties and  exigencies  of  each  particular  case.  The  gouty  diathesis  may  affect 
in  turn  all  the  internal  organs,  as  is  shown  by  the  character  of  the  intestinal 
disorder,  the  palpitation,  the  syncope,  the  dyspnoea,  the  vomiting,  and  head- 
ache. And  this  is  liable  to  occur  periodically  with  those  persons  whose  con- 
stitution is  not  vigorous  enough  to  throw  off"  the  poison  through  the  joints. 
It  is,  in  fact,  an  internal  fit  of  gout,  and  the  treatment  must  be  conducted 
on  general  principles ;  always  bearing  in  mind  the  liability  of  the  brain  to 
be  depressed  by  the  incautious  use  of  sedatives,  and  particularly  of  colchi- 
cum.  When  the  urine  is  loaded,  and  the  evacuations  dark  or  clay-colored, 
mercurials,  podophyllum,  alkalies,  and  salts  of  lithia  may  be  needed  (Form. 
79-80-81-31-33-94).  Carbonate  of  ammonia  will  relieve  the  head,  and 
minute  doses  of  colchicum  may  be  tried  with  it  to  act  as  an  alterative  on 
the  blood  (Form.  16-32).  Of  course  the  same  precautions  are  necessary  as 
in  gout,  viz.,  abstinence  in  eating  and  drinking,  and  taking  regular  exercise.  • 

*  On  Cerebral  Aneemia,  by  Dr.  J.  Milner  Fothergill,  West  Riding  Lunatic  Asylum  Medi- 
cal Reports,  vol.  iv.,  p.  104. 


CHAPTER  XL 


RHEUMATIC    HEADACHE. 


Its  Seat — Causes— Symptoms — Importance  of  Diet  and  Attention  to  the  Digestive  Functions 
— Iodide  of  Potassium — Bark— Colchicum — Baths  and  Waters. 

This  is  occasionally  met  with  in  rheumatic  subjects.  It  affects  the  apo- 
neurosis of  the  scalp,  and  the  occipito-frontalis  and  temporal  muscles.  It 
comes  on  from  exposure  to  cold  in  railway  traveling,  and  from  the  head 
being  uncovered  (especially  when  heated  or  perspiring),  or  by  sudden 
changes  in  the  temperature,  when  north  or  east  winds  prevail.  But  even 
then  it  is  probable  that  there  has  been  some  predisposing  derangement  of 
the  general  health,  or  some  stomach  or  liver  disorder.  The  pain  is  marked 
by  an  aching  and  a  tenderness  of  the  scalp  and  jaws,  severe,  heavy  and  con- 
tinuous ;  there  is  an  aching  too  of  the  teeth  and  gums  (which  are  often  ex- 
quisitely tender),  and  mastication  becomes  painful.  There  is  no  throbbing 
of  the  temporal  arteries,  nor  elevation  in  the  temperature  of  the  scalp,  but 
the  face  is  sometimes  flushed,  the  eyes  are  injected,  and  the  vessels  of  the 
head  and  face  are  loaded  and  excited,  so  that  if  the  patient  is  of  full  habit 
he  gets  a  somewhat  bloated  appearance.  The  pain  increases  in  the  evening, 
and  grows  less  toward  morning.  Dr.  Sieveking  points  out  that,  according 
to  Romberg,  the  pain  is  of  paroxysmal  and  hemicranial  character,  especially 
affecting  the  forehead  and  vertex,  from  which  it  radiates  in  various  direc- 
tions, a  description  which  does  not  completely  accord  with  the  majority  of 
cases  which  have  come  under  my  own  observation.  "I  do  not,"  he  con- 
tinues, "find  that  authors  allude  to  the  possibility  of  an  intracranial  rheu- 
matic affection  ;  but  I  have  repeatedly  met  with  cases  of  cephalalgia  in 
which  no  such  external  indications  presented  themselves,  and  in  which  the 
concomitant  symptoms,  though  but  feebly  marked,  the  history  of  the  case, 
and  the  anti-rheumatic  treatment  adopted,  appear  to  justify  the  conclusion 
that  the  dura  mater,  the  fibrous  envelope  of  the  brain,  was  the  seat  of  the 
disease."*  This  remark  quite  concides  with  my  view  of  the  affection,  for 
the  dura  mater  might  with  as  much  show  of  reasoning  be  expected  to  sympa- 
thize in  rheumatic  headache,  as  that  the  fibro-serous  pericardium  should 
sometimes  be  involved  in  acute  articular  rheumatism. 

Treatment. — For  the  treatment  of  this  headache,  attention  to  diet  is  of 
primary  importance,  in  order  to  counteract  the  rheumatic  tendency.  Vege- 
tables, milk,  and  tapioca  are  preferable  to  animal  food,  and  a  little  dry  wine 
to  beer  and  spirits.  Any  derangement  in  the  digestive  organs  must  be  over- 
come by  suitable  remedies,  in  order  to  restore  the  functions  of  the  bowels, 
skin,  and  kidneys  (Form.  3-19)  ',  and  where  the  local  disorder  has  followed 
a  general  attack,  or  is  complicated  with  neuralgia,  then  iodide  of  potassium, 
bark,  the  alkaline  carbonates,  and  small  doses  of  colchicum  will  be  servicea- 
ble (Form.  36-34-35).  "  I  think  it  almost  certain  that  some  kinds  of  head- 
ache are  produced  by  the  same  morbid  cause  in  the  circulation,  which 
brings  on,  in  other  persons,  or  at  other  times,  true  gouty  affections  of  the 
joints.     With  due  attention  to  the  family  temperament,  to  the  individual 

*0n  Chronic  and  Periodical  Headache,  by  E.  H.  Sieveking,  M.  D.,  F.  R.  C.  P.,  in  Med- 
ical Times  and  Gazette,  1854,  p.  209. 

(97) 


98  HEADACHES. 

habit,  and  particularly  to  their  connection  with  certain  states  of  the  urine, 
it  is  for  the  most  part  easy  to  discriminate  them ;  and  where  thus  attested, 
colchicum  will  generally  be  found  to  act  as  a  safe  and  efficient  remedy."* 
A  sudorific  at  bedtime,  and  a  liniment  to  the  temples  or  nape  of  the  neck 
(Form.  73),  will  often  relieve  the  wearing  pain;  and  I  know  of  one  gentle- 
man who  obtains  most  relief  from  wrapping  up  his  head  in  flannel.  Warm 
clothing  is  very  essential ;  and  if  the  case  is  obstinate,  and  the  patient  has 
the  means  to  procure  change,  he  may  with  advantage  go  to  Vichy,  Ems,  or 
Homburg,  and  take  the  baths  and  waters  there. 

*  On  Gout  as  a  Constitutional  Disease,  in  Medical  Notes  and  Reflections,  by  Sir  H.  Hol- 
land, Bart.,  M.  D.,  F.  R.  S.,  3d  edition,  1855,  p.  267. 


CHAPTER   XII. 

HEADACHE    FROM    AFFECTION    OF   THE    PERIOSTEUM. 

Headache  Attacking  the  Periosteum — Its  Symptoms  and  Treatment- — Large  Doses  of  Iodide 
of  Potassium — Bark — Bichloride  of  Mercury — Small  Doses  of  Calomel — Quinine — Ar- 
senic. 

This  is  met  with  m  the  subjects  of  secondary  syphilis.  It  is  limited  to 
spots  on  the  scalp,  which  are  tender  on  pressure  ;  they  occasionally  present 
some  swelling,  as  is  seen  on  the  skin  and  sternum  when  these  parts  are  af- 
fected with  nodes.  The  pain  is  always  aggravated  at  night.  The  outer  sur- 
face of  the  dura  mater  and  the  bone  are  often  involved  in  syphilitic  inflam- 
mation, leading  to  adhesion  of  the  brain  to  the  affected  spot,  and  even 
suppurative  phlebitis.  A  pink  or  red  swelling  from  congestion  takes  place, 
with  a  caseous  patch  in  the  centre.*  ''Meyer  relates  eight  cases  of  intra- 
cranial disease,  in  which  there  were  found  either  fibrinous  (gummatous) 
tumors  in  the  brain,  or  the  results  of  internal  periostitis  or  inflammation  of 
the  membranes,  besides  more  or  less  marked  indications  of  syphilis  in  the 
liver,  inguinal  glands,  or  other  parts. "f 

Dr.  Symonds  alludes,  in  his  remarks  on  the  headache  of  secondary  syphi- 
lis, to  the  experience  of  Mr.  Spencer  Wells,  who  has  noticed  a  very  striking 
symptom,  pain  across  the  forehead  where  the  brim  of  the  hat  presses.  The 
pain  is  due  to  subacute  frontal  periostitis;  and,  if  the  case  is  bad,  and  the 
S)'Stem  saturated  with  the  syphilitic  poison,  the  specific  inflammation  may 
extend  to  the  membranes,  and  involve  the  brain  itself. 

One  of  the  most  marked  instances  of  this  type  of  headache  came  under 
my  notice  nearly  twenty  years  ago.  The  subject  of  it  was  a  young  officer 
twenty-five  years  of  age,  in  whom  the  syphilitic  cachexia  was  strongly 
marked.  The  pains  in  the  head  (chiefly  frontal)  were  the  latest  manifesta- 
tions of  the  syphilitic  poison,  and  were  the  chief  cause  of  his  quitting  the 
service.  The  natural  placidity  and  cheerfulness  of  his  disposition  were  ex- 
changed for  irritability  of  temper  and  fits  of  passion.  The  attempt  to  alter 
his  position  in  bed,  or  to  give  food  at  the  wrong  moment,  threw  him  into 
an  nucontrollable  fury.  To  this  succeeded  great  exhaustion,  a  feeble  pulse, 
and  a  clammy  skin ;  and  sometimes  nausea  and  vomiting  were  also  present. 
For  some  days  he  would  continue  in  a  state  of  heavy  stupor,  from  which  it 
was  as  difficult  to  rouse  him  as  to  rouse  a  drunken  man.  He  would  turn  his 
face  from  the  light,  knit  his  brows,  and  conceal  his  head  beneath  the  bed- 
clothes. 

Iodide  of  potassium  in  large  doses,  with  tonic  bitters  and  bark,  were  or- 
dered, together  with  small  doses  of  the  bichloride  of  mercury,  from  which 
he  derived  partial  benefit  (Form.  37).  But  eventually  the  condition  grew 
worse,  the  cachexia  increased,  and  the  brain  fell  into  a  state  of  syphilitic 
degeneration,  producing  hemiplegia,  from  which  he  partially  recovered  for 
a  few  months.  Gradually  the  worst  symptoms  returned  ;  he  became  more 
and  more  exhausted,  probably  from  obstruction  in  the  cerebral  vessels,  or 

*  Pathological  Anatomy,  by  Wilks  and  Moxon,  2d  edition,  Philadelphia,  Blakiston,  1875, 
p.   198. 

fNew  Sydenham  Society,  article  Nervous  System,  1862,  p.  79. 

(99)- 


100  HEADACHES. 

lesion  in  one  or  more  of  the  membranes,  and  died  at  the  end  of  a  year 
after  the  head  was  first  affected.  Until  the  paralytic  symptoms  came  on,  the 
external  surface  of  the  head  was  always  tender,  and  at  times  exceedingly 
painful.  No  fluctuation  or  signs  of  matter  were  found  beneath  the  perios- 
teum, which  I  have  known  to  be  the  case  among  soldiers  who  have  had 
syphilis  in  a  bad  form. 

The  treatment  is  the  same  as  was  employed  in  this  case,  iodide  of  potas- 
sium being  the  chief  medicinal  agent.  It  should  be  given  in  full  and  con- 
tinuous doses,  and  not  abandoned  till  forty  or  sixty  grains  have  been  taken 
during  the  day,  freely  diluted  with  water,  and  after  the  principal  meals.  If 
it  is  hastily  given  up  the  case  may  end  fatally,  when  large  and  repeated 
doses  may  cure.  "  The  average  dose  of  iodide  of  potassium  is  from  twenty 
to  thirty  grains  three  times  a  day,  which  is  reached  by  rapid  steps,  from  six 
to  eight  grains  given  at  first.  The  larger  doses  are  necessary.  I  have  re- 
peatedly seen  relapses,  when  the  dose  has  been  at  ten  or  twelve  grains, 
checked  and  cured  by  a  rise  to  twenty-four  or  thirty-six  grains.  I  have 
given  a  drachm  every  four  hours  for  a  short  time,  and  one  patient  came  to 
me  who  had  for  two  or  three  months  taken  this  quantity  three  times  a  day 
with  advantage,  under  the  direction  of  his  family  medical  attendant,  who 
had  '  bettered  '  my  advice  after  a  previous  consultation  with  me.  On  the 
other  hand,  I  have  met  with  cases  in  which  a  single  grain  of  iodide  of  potas- 
sium produced  great  depression  and  other  injurious  effects  ;  in  these  one- 
quarter  or  half  a  grain  may  do  all  the  good,  or  iodide  of  sodium  or  of  am- 
monium maybe  tolerated."*  It  occasionally  happens  that  small  doses  of 
calomel  (gr.  to)  every  two  or  three  hours  relieve  the  pain,  and  prepare  the 
way  for  the  iodide. 

Another  remarkable  case  of  syphilitic  headache  in  a  young  man  fell  under 
my  notice  some  years  ago.  The  patient,  who  was  strong  and  healthy  at  the 
time  when  he  contracted  syphilis,  took  an  abundance  of  mercury,  which 
greatly  reduced  him,  and  encouraged  the  ulcerative  process.  Severe  secondary 
symptoms  ensued,  with  nodes  on  the  cranium  and  tibise,  which  produced 
foul  suppurating  sores,  and  caries  of  the  affected  bones.  Alarming  epileptic 
seizures  followed,  accompanied  by  great  irritation  of  the  brain  and  mem- 
branes, and  his  life  was  often  despaired  of.  When  a  sore  on  the  leg  or  foot 
discharged  freely,  it  favored  the  escape  of  the  syphilitic  poison,  and  consid- 
erably modified  the  cerebral  symptoms.  The  treatment  consisted  in  strict 
attention  to  hygienic  rules,  the  fresh,  pure  air  of  the  country,  and  a  gener- 
ous diet.  The  remedies  prescribed  in  the  shape  of  drugs  were  iodide  of  po- 
tassium, quinine,  and  arsenic  (Form.  38).  Under  their  separate  and  com- 
bined use,  and  that  great  power  which  nature,  if  allowed  time,  possesses  to 
remove  morbid  products,  when  the  inernal  organs  have  escaped  structural 
mischief,  the  patient  perfectly  recovered,  and  is  now  in  as  good  a  state  of 
health  as  any  person  of  his  age  could  expect  to  be. 

In  cachetic  conditions  mercury  may  be  given  with  advantage,  and  without 
detriment  to  the  patient,  if  combined  with  iron  (Form.  4). 

*0n  Syphilitic  Affections  of  the  Brain,  by  W.  H.  Broadbent,  M.  D.,  in  the  Lancet,  Nov. 
25th,  1876. 


CHAPTER  XIII. 

ORGANIC    HEADACHE. 

Character  of  the  Pain  in  Organic  Headache,  Continuous,  Limited,  or  Paroxysmal— The 
General  Symptoms  Assist  in  the  Diagnosis  of  the  Cerebral  Changes — Often  Due  to  Ather- 
omatous Degeneration  in  the  Cerebral  Vessels — Terminations  in  Apoplexy  and  Paralysis 
—Usual  Causes  of  Organic  Pleadache — Cysts — Hydatids — Exostoses — Syphilis — Value 
of  Large  Doses  of  Iodide  of  Potassium  in  all  Cases  of  Cerebral  Tumor,  whether  due  to 
Syphilis  or  not — Rest  to  be  Procured  by  Bromide  of  Potassium  and  Hydrate  of  Chloral 
— If  all  Hypnotics  fail,  the  Hypodermic  Injection  of  Morphia  to  be  Employed. 

Organic  headache  (^Cephalalgia  organica)  is  called  "Structural  Head- 
ache ' '  by  Dr.  Symonds,  but  I  prefer  the  term  organic,  because  it  is  more 
clearly  expressive  of  the  grave  morbid  changes  which  provoke  it,  such  as 
tuberculous,  cancerous,  or  syphilitic  tumors,  hydatids,  ossific  formations 
within  the  cranium,  softening  of  the  brain,  adhesion  of  the  membranes,  ar- 
terial degeneration,  aneurism,  obstruction  of  the  sinuses,  and  so  forth.  But 
disease  of  the  brain  from  any  of  these  causes  iTiay  be  present  without  our 
being  able  to  recognize  its  nature  or  its  extent,  as  in  the  case  of  the  late 
Professor  J.  Plughes  Bennett.  A  tumor  may  exist  and  cause  neither  head- 
ache nor  any  cerebral  disturbance,  if  the  membranes  are  not  stretched,  and 
inflammation  does  not  ensue.  When  either  of  these  results  follows,  then 
symptoms,  which  till  then  have  been  obscure  and  perplexing,  are  occasionally 
cleared  up.  The  brain  accommodates  itself  to  pressure  when  it  is  gradual 
and  brought  about  slowly,  and  thus  the  encroachment  is  not  resented,  owing 
to  a  new  adjustment  of  the  circulation,  and  balance  of  the  various  structures 
within  the  cranium.  Before  pain  is  complained  of,  there  is  sometimes 
impairment  of  function,  as  in  the  case  of  a  small  tumor,  or  softening  at  the 
origin  of  the  third  nerve,  by  no  means  an  uncommon  accompaniment  of 
organic  headacne  ;  and  we  derive  important  and  conclusive  evidence  of  the 
situation  of  the  lesion,  when  the  patient  does  not  complain  of  the  sensation 
of  headache,  and  is  able  to  follow  his  usual  duties.  Yet  on  the  other  hand, 
a  tumor  has  been  found  to  occupy  the  centre  of  one  of  the  hemispheres  of 
the  brain,  or  ventricles,  and  to  cause  no  disorder  of  motion  or  special  sen- 
sation, no  failing  sight,  no  impairment  of  intellect,  no  threatening  palsy. 
Pain  in  the  head  has  been  the  one  single  and  constant  symptom,  sometimes 
even  intermitting,  and  coming  on  in  paroxysms.  This  depends  on  some 
varied  condition  of  the  circulation.  Paroxysmal  pain  is  often  observed  in 
structural  disease  of  the  brain,  from  the  liability  of  all  nervous  pain  to  take 
on  this  peculiar  feature ;  but  if  pain  is  intense  and  continuous,  and  is  re- 
ferred to  one  particular  spot,  some  organic  lesion  may  be  suspected.  The 
headache  which  never  yields  for  a  moment  to  any  treatment  may  be  safely 
put  down  as  organic.  The  pain  of  organic  headache  is  an  abiding  and 
continuous  agony;  it  enters  into  every  thought,  and  the  patient  lies  in 
some  obscure  corner  of  the  house,  or  in  bed,  silently  enduring  the 
maddening  pain,  with  the  saddest  and  most  pitiable  expression.  He 
can  do  nothing,  and  think  of  nothing  ;  it  is  impossible  to  distract  his 
attention  in  such  a  way  as  to  convince  one  that  he  is  ever  entirely 
free  from  pain.  "  Dr.  Hughlings  Jackson  remarks  that  frontal  head- 
ache is  generally  referable  to  abdominal  affections,  vertical  headache  to 
cerebral  disturbance,    and  occipital  pains   to  disorders  of  the  circulation, 

(lOl) 


102  HEADACHES. 

and  more  especially  to  anEemia.  However  that  may  be,  it  is  certain 
that  the  pain  due  to  cerebral  disease  may,  especially  in  the  case  of  cere- 
bral tumors,  be  referred  to  all  parts  of  the  head,  and  that  this  pain  may 
exactly  simulate  those  which  are  of  no  less  serious  origin.  It  may  be  slight 
or  intense,  continuous  or  paroxysmal;  may  be  attended  with  tenderness  of 
the  scalp,  or  with  several  of  the  symptoms  which  have  been  already  referred 
to  as  frequent  accompaniments  of  headache.  When  the  pain  is  intense,  and 
especially  if  it  be  paroxysmal,  it  frequently  causes  the  patient  to  scream  out, 
and  to  support  his  head  with  his  hands.  The  most  intense  pain,  which  is 
then  usually  very  limited  as  to  its  seat,  is  induced  by  the  pressure  of  intra- 
cranial tumors  or  abscesses  upon  sensory  nerves."*  Dr.  Walshe's  experience 
concerning  the  diagnosis  of  a  cerebral  tumor  is  much  to  the  same  effect. 
He  says,  "  The  circumstances  most  distinctly  permitting  the  physician  to 
affirm  that  a  tumor  exists  within  the  cranium  are :  the  existence  for  a  con- 
siderable period  of  intense  cephalalgia,  especially  if  limited  to  a  fixed  point, 
or  even  to  one  side  of  the  head,  and  if  attended  with  repeated  vomiting;  of 
convulsive  movements  without  paralysis,  but  followed  by  mere  weakness,  or 
actual  paralysis  of  the  affected  parts ;  of  different  affections  of  the  organs  of 
sense,  especially  alteration  of  sight,  and  of  disturbance  of  intellect,  while  the 
general  health  does  not  very  materially  suffer,  "f 

It  is  obvious  that  the  pain,  as  a  rule,  varies  according  to  the  size  and  seat 
of  the  tumor,  and  the  pressure  to  which  the  several  nerves  are  subjected ; 
but  when  it  is  remembered  that  a  tumor  may  attain  considerable  magnitude 
before  it  causes  pain  or  inflammation,  the  subject  of  diagnosis  is  confessedly 
obscure.  Dr.  Abercrombie  relates  a  class  of  cases,  which  are  often  mistaken 
for  periodical  or  sick  headache,  the  pain  not  being  urgent  enough  to  invite 
attention  to  the  head  as  the  origin  of  the  mischief,  but  to  the  stomach  as  the 
supposed  offender.  After  death  the  chief  morbid  appearances  are  found  in 
the  cerebellum.  There  are  cases,  too,  in  which  giddiness,  failing  muscular 
power,  loss  of  sight  and  recollection,  are  the  chief  features ;  but  there  is  no 
headache  whatever,  and  exemption  from  it  may  be  possibly  owing  to  degen- 
erative changes  in  the  nervous  tissue,  rather  than  to  pressure  on  membranous 
structures,  and  congestion  of  the  cerebral  vessels. 

Organic  headache,  then,  is  distinguished  by  the  continuance  of  the  suffer- 
ing, which  either  extends  over  the  entire  brain,  or  is  deeply  seated  in  one 
spot.  It  occasionally  resembles  the  congestive  form  of  headache  from  over- 
distension of  vessels,  which  is  so  frequently  present;  though  some  cases 
exhibit  pallor  and  anaemia,  with  much  pain.  Some  years  ago  a  man,  aged 
forty,  came  under  my  care,  who  suffered  the  most  excruciating  agony  in  the 
vertex  and  left  side  of  the  head,  from  which  he  never  had  a  moment's  re- 
spite, and  his  agony  was  so  acute  that  he  longed  for  death.  Though  there 
was  at  no  time  of  his  early  illness  any  symptom  of  paralysis,  or  loss  of  mem- 
ory or  sensation,  it  was  conjectured  that  he  was  suffering  from  disease  of  the 
brain,  because  the  pain  was  continuous  and  fixed,  and  his  expression  vacant 
and  desponding.  His  forehead  was  wrinkled,  his  brows  drooping,  and  his 
eyes  had  lost  all  animation.  In  the  course  of  a  few  weeks,  whilst  under 
observation,  delirium  came  on,  accompanied  by  vomiting,  and  inability  to 
retain  any  food  on  his  stomach.  These  symptoms  continued,  and  he  fell 
into  a  comatose  condition  and  died.  After  death  a  cancerous  tumor  was 
found  in  the  left  hemisphere,  extending  posteriorly  and  downwards  to  the 

*The  Tlieory  and  Practice  of  Medicine,  by  Dr.  Bristowe,  1876,  p.  942. 

f  The  Nature  and  Treatment  of  Cancer,  by  W.  H.  Walshe,  M.  D.,  1S46,  p,  495. 


ORGANIC    HEADACHE.  IO3 

margin  of  the  left  lateral  ventricle,  but  not  to  the  deeper  structures  at  the 
base  of  the  brain. 

The  presence  of  febrile  symptoms,  with  rigors  and  high  temperature, 
where  there  is  pain  in  the  head,  would  help  us  to  the  diagnosis  of  the 
organic  change  within  the  cranium,  as  in  tubercular  mischief,  or  the  forma- 
tion of  an  abscess.  When  headache  in  a  young  adult  man  comes  on  with 
symptoms  approaching  convulsion,  or  epileptic  seizure,  and  there  is  any 
amount  of  facial  paralysis  or  thickening  of  speech,  it  is  suggestive  of  organic 
origin,  and  more  especially  so  if  there  is  a  history  of  syphilis.  If  vomiting 
be  added  to  the  list  of  symptoms,  it  is  all  the  more  likely,  particularly  if  no 
relief  follows,  which  generally  does  follow  if  the  headache  be  due  to  gastric 
disorder.  It  comes  on  suddenly,  and  the  patient  may  be  able  and  willing  to 
take  food  immediately  after  the  contents  of  the  stomach  have  been  expelled. 

This  headache  is  witnessed  in  softening  of  the  brain,  where  the  blood- 
vessels are  diseased  from  atheromatous  deposit.  In  a  female  patient,  aged 
seventy,  who  was  under  my  care  in  1875  f^^  this  headache  (which  she  de- 
scribed as  unceasing  and  occupying  the  whole  frontal  region),  there  were 
present  most  of  the  symptoms  which  accompany  disease  of  the  brain,  such  as 
depression  of  spirits,  the  apprehension  of  some  impending  calamity,  and  the 
gradual  failure  of  the  intellectual  powers.  No  treatment  was  available  in 
removing  the  headache,  and  it  is  probable  the  termination  is  not  far  distant 
in  a  paralytic  or  apoplectic  seizure.  In  this  case,  as  in  many  similar  cases, 
there  was  more  confusion  of  ideas  than  pain. 

In  1867  a  gentleman,  aged  seventy-four,  consulted  me  for  frontal  head- 
ache, which  was  so  overpowering,  that  in  my  presence  he  often  wished  for 
deliverance  by  death.  He  had  had  two  slight  apoplectic  seizures  in  1866,  due 
to  cerebral  haemorrhage.  There  was  atheromatous  change  in  this  case,  and 
the  radial  and  temporal  arteries  gave  indications  of  hardness  and  tortuosity; 
depression  of  spirits  and  irritability  of  mind  and  manner  were  also  noticeable 
features  of  his  changed  condition.  After  dinner  the  headache  was  generally 
relieved  by  a  larger  quantity  of  wine  than  was  allowable,  and  next  morning 
the  pain  and  confusion  of  ideas  were  increased.  In  this  case  much  relief 
was  obtained  by  carbonate  of  ammonia  and  calumba  (Form.  54),  and  by 
valerianate  of  zinc  and  hop  in  the  form  of  a  pill  (Form.  105),  and  ammonia 
and  tincture  of  lavender  (Form.  55).  A  few  months  before  his  death,  in 
August,  1868,  from  sudden  apoplexy  and  hemiplegia,  he  had  quite  lost  his 
headache,  and  the  condition  of  the  brain  did  not  appear  worse  until  the 
time  of  his  fatal  illness. 

Among  the  causes  of  organic  headache,  a  blow  on  the  head,  received  at 
an  early  period  of  life,  may  eventually  provoke  a  change  in  the  vessels  which 
leads  on  to  organic  disease.  A  slow  insidious  congestion  or  inflammation 
may  end  in  mischief  by  causing  a  local  pressure,  impeding  the  circulation  in 
some  parts,  and  increasing  it  in  others.  Dr.  Moxon  says:  "The  organic 
causes  of  great  headache  are  never  diseases  of  the  proper  nervous  tissue,  but 
always  diseases  of  its  enveloping  textures."*  Here  it  is  right  to  state  that 
this  view  is  open  to  some  question.  "It  may  be  well  briefly  to  advert  to 
the  ratio  in  which  cephalalgia  occurs  in  organic  affections  of  the  intracranial 
contents,  determined  by  cadaveric  inspection.  We  shall  find  that  it  is  a 
symptom  of  less  frequent  occurrence  than  we  might  have  anticipated,  a  fact 
which  negatively  demonstrates  the  necessity  of  additional  care  in  attending 
to  other  signs  indicating  disturbance  of  the  nerve-centres.  The  analysis  of 
authentic  cases  of  this  description  also  shows  that  there  is  no  definite  rela- 

*Dr.  Moxon,  On  the  Treatment  of  Headache  from  Intracranial  Disease,  in  Lancet,  May 
29th,  1875,  P-  750- 


I04  HEADACHES. 

tion,  except  in  the  instance  of  the  cerebellum,  between  the  site  of  the  lesion 
and  the  site  of  the  previous  pain."  Taking  the  diseases  of  the  cerebrum 
and  cerebellum  together  (apoplectic  and  non-apoplectic  cases),  furnished  by 
Andral  and  Dr.  Abercrombie,  "we  find  that  the  ratio  in  which  headache  is 
a  concomitant  of  organic  disease  of  the  brain  is  as  92  to  38,  or  nearly  as  3 
to  I ;  while  by  eliminating  the  apoplectic  cases,  we  obtain  the  still  higher 
ratio  of  74  to  15,  or  nearly  5  to  i."*  "In  twenty  cases  of  fungus  of  the 
dura  mater,  published  by  Louis  (Mem.  de  V  Acad.  Roy.  de  Chir.,  t.  5), 
there  were  only  three  with  cerebral  symptoms  of  any  kind;  and  chronic 
abscesses,  cysts,  hydatids,  exostoses,  etc. ,  have  often  arrived  at  an  enormous 
size  without  having  produced  any  serious  alteration  in  the  functions  of  the 
brain,  "f 

Treatment. — Here  our  first  steps  are  to  ascertain  what  is  the  cause  of  the 
headache,  and  in  what  way  we  ought  to  proceed  to  arrest  the  inflammation 
or  the  pain  which  has  been  set  up.  Dr.  Moxon  considers  that  organic 
headache  occurring  in  the  earlier  decades  of  adult  age  demands  large  doses 
of  iodide  of  potassium,  and  that  it  even  yields  to  this  drug  when  not  of  a 
syphilitic  nature.  It  must  be  evident,  as  he  says,  to  most  observers,  that 
syphilis  may  affect  the  system  without  our  being  able  to  trace  any  hereditary 
history  of  it,  or  to  find  any  evidence  of  it  on  the  skin  or  bones  of  the  body. 
When  the  iodide  does  afford  relief  to  the  suffering,  I  am  strongly  inclined  to 
think  there  is  some  undiscovered  syphilitic  taint,  for  I  have  seen  many  cases 
of  confirmed  headache,  supposed  to  be  due  to  organic  change,  both  in  young 
and  old  persons,  who  have  derived  no  advantage  from  the  drug;  on  the  con- 
trary, the  pain  has  increased  under  its  use.  In  one  case  of  syphilitic  head- 
ache, the  iodide,  which  gave  relief  at  first,  failed  altogether  in  the  latter 
period  of  the  patient's  life;  and  in  another  case  the  drug  made  the  patient 
much  worse  at  first,  but  better  afterwards.  It  may  be  given  in  small  doses, 
sometimes  combined  with  the  bicarbonate  of  potash  and  small  doses  of  sal 
volatile  (Form.  56)  ;  but  as  many  as  forty  or  sixty  grains  should  be  given  in 
the  course  of  the  day,  if  there  be  a  suspicion  of  syphilis  and  the  pain  is  con- 
tinuous. Dr.  Smith  recommends  iodide  of  potassium  in  all  cases  of  head- 
ache due  to  cerebral  tumor.  If  the  growth  depends  on  syphilis,  it  may  cure 
the  condition  entirely;  and,  if  not,  it  has  been  known  to  relieve  the  pain 
and  local  congestion  induced  by  other  swellings;  so  that  the  remedy  is  worth 
a  trial  in  all  cases  that  appear  obstinate. 

Bromide  of  potassium  and  hydrate  of  chloral  will  be  necessary  to  procure 
rest  if  the  patient  is  wakeful  and  can  obtain  no  sleep;  bet  if  these  remedies 
fail,  with  other  suitable  hypnotics,  then  the  subcutaneous  injection  of  mor- 
phia may  be  tried,  and  the  observations  I  have  elsewhere  made  are  also 
applicable  here.  J  Dr.  Moxon  found  that  gr.  \  of  morphia,  used  hypoder- 
mically,  gave  relief  in  a  syphilitic  case  after  the  iodide  failed;  but  he  urges 
caution,  from  its  liability  to  produce  insensibility;  and,  apart  from  the 
possibility  of  this  contingency,  it  does  induce  very  serious  depression  and 
mental  disturbance  in  some  persons,  even  when  the  operation  is  carefully 
performed  and  the  quantity  used  very  small.  When  the  pain  is  severe  and 
yields  to  nothing  else,  it  ought  to  be  tried. 

*On  Chronic  and  Periodical  Headache,  by  E.  H.  Sieveking,  M.  D.,  F.  R.  C.  P.,  in 
Medical  Times  and  Gazette,  1854,  p.  181. 

f  Tweedie's  Practical  Medicine,  article  Cephalalgia,  1840,  vol.  ii.,  p.   154. 

%  See  Chapter  VII,  on  Nervous  Headache. 


CHAPTER  XIV. 

HEADACHES  OF  ADVANCED  LIFE. 

These  can  scarcely  be  separated  from  the  headaches  of  organic  disease, 
there  being  in  all  likelihood  some  change  of  structure;  the  vessels  become 
brittle  and  atheromatous,  and  the  circulation  through  the  brain  is  impeded 
and  deficient.  There  are  many  of  the  changes  that  may  be  looked  for  in 
the  decline  of  life,  when  the  physical  frame  grows  feebler  and  weaker,  and 
the  tissues  are  but  slowly  renovated.  In  some  persons  of  full  habit,  who  are 
advanced  in  life,  the  headaches  are  of  a  congestive  type,  and  therefore  any 
excitement  of  the  circulation,  as  overeating,  or  too  great  indulgence  in 
stimulants,  may  cause  the  vessels  to  rupture,  and  so  an  apoplectic  seizure  be 
induced;  for,  the  brain  having  undergone  softening  change  through  the 
failure  of  nutrition,  the  withdrawing  of  this  support  renders  the  vessels  ex- 
ceedingly liable  to  rupture  from  any  sudden  strain  which  may  be  put  upon 
them. 

In  cases  of  headache  dependent  upon  cerebral  softening,  the  suffering  is 
less  acute  than  in  most  other  of  the  organic  varieties,  and  irritability  and  fits 
of  depression  are  more  common.  Dr.  Herbert  Major  demonstrates  that  the 
large  nerve-cells  are  in  a  state  of  granular  degeneration  in  senile  atrophy  of 
the  brain,  and  that  the  smaller  cells  are  simply  atrophied  without  degenera- 
tion.* It  is  highly  probable  that  many  of  the  morbid  changes  found  in 
senile  atrophy  of  the  brain  are  the  cause  of  the  headaches  of  advanced  life, 
and  also  those  headaches  which  we  ascribe  to  organic  change.  We  cannot 
expect  that  we  shall  find  anything  at  all  constant  in  character  with  the  various 
morbid  conditions  of  the  brain. 

Treatmeiit. — If  there  is  a  tendency  to  congestion  about  the  head,  it  should 
be  controlled-  by  those  remedies  which  naturally  suggest  themselves  to  the 
practitioner.  A  mild  aperient  and  cold  sponging  the  head  night  and  morn- 
ing will  be  found  serviceable  (Form.  8i).  In  the  case  of  one  patient  who 
had  confirmed  headache  from  cerebral  degeneration,  I  found  that  a  large 
sponge  filled  with  water,  and  allowed  gradually  to  empty  itself  over  the  top 
of  the  head  night  and  morning,  gave  more  relief  than  any  other  remedy  that 
was  tried;  it  calmed  the  excitement,  promoted  sleep,  and  refreshed  the 
patient,  so  that  he  was  able  to  walk  a  short  distance  with  comparative  com- 
fort after  it.  When  cold  is  thus  locally  applied,  it  has  a  tonic  and  invigorat- 
ing effect.  By  contracting  the  vessels  and  lessening  the  supply  of  blood  to 
the  brain,  it  retards  the  cell  growth  and  other  degenerative  changes  in  the 
tissues. 

Ergot  of  rye  is  a  useful  remedy,  and  has  been  given  with  benefit  in  these 
cases.  It  causes  contraction  of  the  vessels  through  its  influence  on  the 
sympathetic  system,  and  our  experience  of  its  efficacy  in  the  treatment  of 
uterine  haemorrhage  and  haemoptysis  entitles  it  to  a  most  prominent  position 
among  styptic  agents.  Twenty  to  thirty  minims  of  the  liq.  extract  ergot,  in 
water,  with  a  few  drops  of  spirit  of  chloroform,  three  times  a  day,  is  a  fair 

*  Observations  on  the  Histology  of  the  Morbid  Brain,  in  West  Riding  Lunatic  Asylum 
Reports,  1874,  vol.  iv.,  p.  223. 

7  (105) 


I06  HEADACHES. 

dose  (Form.  57),  but  Dr.  Smith*  recommends  much  large  doses.  He  begins 
with  one  drachm  of  the  same  preparation,  and  increases  it  to  half  an  ounce 
three  times  a  day  (Form.  58).  If  the  theory  is  correct  regarding  the  action 
of  ergot,  these  large  doses  are  not  advisable.  In  small  doses  it  is  known  to 
contract  the  arterioles  very  considerably,  but  in  large  doses  it  leads  to  ex- 
haustion and  subsequent  dilatation.  Judging  from  the  headache  which  it 
sometimes  induces  when  used  in  menorrhagia,  smaller  doses  are  preferable, 
and  in  most  cases  will  be  found  equally  effectual.  If  these  measures  fail  to 
afford  relief,  and  the  patient  is  in  so  much  pain  that  sleep  cannot  be 
obtained,  opium  alone,  or  the  bromide  and  chloral  mixture,  must  be  resorted 
to,  and  in  doses  full  enough,  and  as  often  repeated  as  the  urgency  of  the 
case  appears  to  warrant. 

The  treatment  also  comprises  fresh  air,  light  food,  and  cheerful  conversa^ 
tion ;  for  there  is  a  risk  in  confirmed  cases  of  the  mind  becoming  so  weak, 
that  the  patient  may  end  his  days  in  a  lunatic  asylum. 

*  Therapeutics  of  Headache,  by  A.  A.  Smith,  M.  D.,  a  lecture  delivered  at  Bellevue 
Hospital  Medical  College,  in  Medical  Record,  September  15th,  1876. 

The  action  of  ergot  is  further  alluded  to  in  Chapter  H.,  on  theHeadache  of  Cerebral 
Hypersemia. 


CHAPTER  XV.    ' 

NEURALGIC    HEADACHE. 

Relation  to  Nervous  Headache — Its  Origin  traceable  to  Decayed  Teeth  and  other  Local 
Causes  of  In-itation,  as  Changes  of  Weather  and  Uterine  and  Intestinal  Disturbance — Its 
Origin  in  the  Special  Poison  of  Ague — Pain  precedes  Sickness,  and  is  not  relieved  by 
Vomiting,  as  in  the  Dyspeptic  or  Bilious  Headache — Acute  Hearing  a  premonitory  Symp- 
tom— Hard  Work  a  common  Cause — Cases  in  Illustration — Renal  Cirrhosis  a  cause  of 
Hemicrania. 

Treatment — Nutritious  Diet — Local  and  General  Stimulants — Bitter  Ale — Brandy  and 
Water — Rest  and  Full  Doses  of  Quinine — Carbonate  and  Hydrochlorate  of  Ammonia — 
Veratria  and  Aconitina  Ointments — Hypodermic  Injection  of  Morphia — Valerianate  of 
Zinc — Phosphorus — Strychnia — Cannabis  Indica — Arsenic — Iron — Cod-liver  Oil. 

This  is  really  one  form  of  nervous  headache.  It  affects  one  side  of  the 
head  and  face  (hemicrania,)  or  it  fixes  on  one  particular  spot,  causing  a 
sensation  as  though  a  nail  Vv^ere  being  driven  through  the  head  (clavus  hys- 
tericus).* It  frequently  proceeds  from  decayed  teeth,  or  some  other  local 
cause  of  irritation,  which  may  depress  the  nervous  system  and  weaken  the 
appetite  and  digestive  functions. f  It  is  one  form  of  neuralgia  like  tic  doulou- 

*  With  regard  to  these  definite  and  tender  spots  having  their  origin  in  the  fifth  nerve,  Dr. 
Anstie  thus  writes:  "Ever  since  the  time  of  Valleix,  most  authors  have  disposed  of  this 
question  summarily,  by  inquiring  as  to  the  existence  or  non-existence  of  certain  tender  points 
at  particular  situations  in  the  course  of  various  branches  of  the  fifth  nerve.  Supposing  it 
were  possible  that  a  patient  should  be  affected  wiih  universal  and  equally  violent  neuralgia 
of  all  the  principal  branches  of  the  nerve,  the  situations  in  which  the  most  important  of  these 
painful  points  would  be  developed  are  such  as  you  see  marked  on  the  diagram :  i.  The 
parietal  point.  2.  The  supraorbital.  3.  The  trochlear.  4.  The  palpebral.  5.  The  ocular. 
6.  The  nasal.  7.  The  infraorbital.  8.  The  malar.  9.  The  superior  labial.  10.  The 
mental.  11.  The  auriculo-temporal.  Pressure  on  any  of  these  points,  even  in  the  intervals 
of  the  neuralgic  attacks,  causes  an  exquisitely  acute  pain  to  dart  along  to  the  terminal 
branches  which  lie  external  (peripheral)  to  the  tender  spot." — "  Lettsomian  Lectures  on 
Certain  Painful  Affections  of  the  Fifth  Nerve,"  by  F.  E.  Anstie,  M.  D.,  in  The  Lancet, 
August  25th,  1866,  p.  200. 

f  "A  gentleman  had  for  many  years  been  liable  to  attacks  of  headache  on  the  slightest 
provocation.  Long- continued  intellectual  exertion,  the  excitement  of  an  agreeable  party,  a 
journey,  any  error  of  diet,  would  inevitably  lead  to  an  attack  of  headache.  During  the  same 
period  he  suffered  at  different  times  from  pain  in  his  teeth,  which  decayed  rapidly,  and  at 
last  were  removed  and  replaced  by  false  ones.  This  change  happened  more  than  a  year 
ago,  and  since  tlrat  time  he  has  been  almost  exempt  from  pain  in  the  head.  In  other  re- 
spects his  health  and  mode  of  life  have  been  unaltered.  What  was  the  connection  between 
the  diseased  teeth  and  the  headache  ?  The  morbid  impressions  on  the  ganglionic  fibres  of 
the  fifth  pair  might,  without  any  stretch  of  hypothesis,  be  reasonably  presumed  to  induce  a 
morbid  state  of  the  Gasserian  ganglion,  whether  the  impressions  on  the  sensory  fibres  did  or 
did  not  reach  the  sensorium,  and  induce  a  painful  sensation  referred  to  the  teeth.  The 
Gasserian  ganglion  is  connected  by  marked  fibres  with  the  cephalic  ganglion,  from  which  a 
large  number  of  nerves  pass  to  the  cerebral  arteries.  The  cephalic  ganglion  probably  par- 
took of  the  morbid  condition  of  the  Gasserian,  and  hence  might  have  arisen  so  susceptible  a 
state  of  the  ganglionic  nerves  of  the  brain  that  they  may  have  become  disposed  to  ache 
under  the  influence  of  impressions  which,  without  the  predisposition  in  the  nerves,  produced 
in  the  manner  I  have  described,  would  have  no  effect.  It  seems  to  me  that  if  this  explana- 
tion cannot  be  accepted,  there  is  no  alternative  but  the  supposition  that  morbid  inrpressions 
on  the  dental  nerves  (not  creating  pain  in  those  parts),  arriving  at  the  central  exremities  of 
the  nerves,  are  passed  on  to  that  part  of  the  sensorinm  which  is  related  with  the  sensory 
fibres  of  the  ganglionic  nerves  of  the  brain,  and  maintain  in  that  part  of  the  sensorium  a 
morbidly  susceptible  condition  ;  and  that  this  condition  is  brought  into  such  action  as  con- 

(107) 


I08  HEADACHES. 

reux,  and  the  paroxysm  may  come  on  after  regular  and  short  intervals  of 
ease,  or  after  irregular  and  long  intervals.  I  have  often  met  with  it  in 
women  out-patients  who  come  periodically  to  get  relief  after  hard  work  or 
poor  living;  and  this  they  find  in  full  doses  of  quinine,  and  in  rest.  Any 
causes  that  induce  excitement  or  exhaustion,  as  severe  leucorrhoea,  or  other 
uterine  loss,  will  bring  it  on  in  subjects  who  are  predisposed  to  it.  Women 
drained  from  menorrhagia  are  as  common  victims  to  this  variety  as  they  are 
to  any  form  of  nervous  headache.  I  could  enumerate  many  examples  of 
acute  suffering  from  this  cause,  in  which  the  periods  of  intermission  were 
very  short,  and  the  local  mischief  that  followed  was  obstinate  and  trouble- 
some; impaired  motion  of  the  affected  eyelid,  conjunctivitis,  and  excessive 
secretion  from  the  lachrymal  gland,  may  all  be  looked  for  in  severe  cases. 
Sometimes  the  disease  is  distinctly  intermittent,  like  an  attack  of  ague,  and 
it  is  commonly  traceable  to  the  same  exciting  causes.  From  my  own  experi- 
ence I  should  say  that  neuralgia  of  malarial  origin  is  very  rare,  at  least  in 
London  practice.  The  improved  dwellings  of  the  poor  throughout  the 
country,  and  the  better  drainage  of  the  soil,  which  has  rendered  the  ground 
more  productive  and  easier  of  cultivation — two  powerful  means  of  improving 
the  physical  and  elevating  the  moral  nature  of  man — have  reduced  this 
cause  very  considerably.  With  these  changes  in  human  progress,  the  spread 
of  malaria  and  fevers  of  all  kinds  have  greatly  diminished.  When  neuralgia 
is  present  from  this  cause,  it  affects  the  fifth  nerve,  or  some  of  its  branches, 
and  the  periodicity  may  be  as  regular  as  a  quotidian  or  tertian  ague.  The 
true  neuralgic  headache  seldom  extends  over  the  whole  head,  or  produces 
sickness  or  vomiting,  unless  the  attack  has  lasted  long  and  is  very  severe.  I 
should  limit  its  strict  definition  to  the  intensity  of  the  suffering,  and  its 
superficial  seat;  to  the  paroxysmal  character  of  the  pain,  and  its  extension 
in  the  course  of  the  superior  branch  of  the  fifth  nerve,  and  those  filaments 
which  supply  the  orbit,  inner  angle  of  the  eye,  and  forehead.  I  would  here 
say,  however,  that  the  pain  in  some  cases  appears  to  enter  the  eye  or  the 
brow,  to  pierce  through  the  centre  of  the  head  and  to  escape  at  the  occiput, 
or  to  find  its  way  out  through  the  neck,  arms,  and  legs.  The  pain  in  the 
limbs  resembles  a  pricking  or  numbness,  and  the  patient  suddenly  finds, 
whilst  engaged  in  writing,  that  he  cannot  hold  or  control  his  pen,  and  he 
then  becomes  apprehensive  of  paralysis.  I  have  met  with  several  instances 
of  the  kind.     Phosphates  are  frequently  present  in  the  urine. 

In  this  headache,  as  in  the  nervous  variety,  the  pain  precedes  the  sickness, 
and  is  not  relieved  by  vomiting.  The  patient  vomits  incessantly,  till  almost 
torn  in  two  by  the  violence  of  the  retching,  and  only  brings  up  some  frothy 
watery  mucus — not  a  vestige  of  bile;  but  in  the  vomiting  of  dyspeptic  head- 
ache, or  from  indulgence  in  alcoholic  drinks,  the  nausea  and  vomiting  pre- 
cede the  headache,  and  afford  relief  from  the  removal  of  the  cause. 

Extreme  sensibility  to  sound  of  any  kind,  or  a  distressing  acuteness  of 
hearing,  is  an  occasional  accompaniment  of  neuralgic  headache.  I  am 
acquainted  with  the  case  of  a  married  lady  who  has  long  been  in  delicate 
health  from  spinal  weakness,  and  whose  decayed  teeth  have  partly  induced 
the  attacks  of  neuralgia  in  the  head.  When  she  is  suffering  from  hemicrania 
she  can  hear  the  ticking  of  a  clock  in  an  adjoining  room,  in  which  she  can- 
not even  hear  it  strike  when  she  is  free  from  headache.     The  ticking  of  her 

stitutes  pain,  whenever  the  said  part  of  the  sensorium  receives  impressions  transmitted  from 
nerves  which  have  been  offended  by  causes  acting  directly  upon  them  in  the  brain  itself,  as 
in  overstudy  or  anxiety,  or  when  it  lias  received  like  disturbing  impressions  from  the  nerves 
of  other  parts  of  the  ganglionic  system." — Symonds,  on  Headache,  in  Medical  Times  and 
Gazette,  April  3d,  1858,  p.  339. 


NEURALGIC  HEADACHE.  IO9 

own  watch,  and  that  of  any  other  person  in  the  same  apartment,  is  quite 
annoying,  if  not  ahnost  unendurable  to  her.  Another  peculiar  feature  of 
the  case  is,  that  the  patient  knows  when  an  attack  of  headache  is  threatening 
by  her  hearing  becoming  suddenly  acute,  and  when  the  attack  is  likely  to 
pass  off,  by  a  declme  in  its  sensibility. 

Excitement  of  all  kinds  will  bring  this  headache  on,  as  the  noise  of  railway 
travelling,  and  any  bustle  or  confusion;  but  it  is  more  frequently  attributable 
to  disordered  digestion,  and  to  changes  in  the  weather,  than  to  causes 
operating  on  the  brain  itself.  It  is  most  frequent  in  adult  or  middle  life, 
and  is  far  less  common  in  children ;  *  but  if  it  happens  to  those  advanced  in 
years,  when  degenerative  changes  are  established,  it  is  often  severe,  protracted, 
and  obstinate.  It  may  be  noticed  that  other  neuralgias  are  equally  common 
at  this  period  of  life,  as  sciatica,  pleurodynia,  angina  pectoris,  and  gastralgia. 
I  consider  oversuckling  a  most  fertile  cause  in  women,  and  among  hospital 
patients  it  is  common  enough,  when  they  have  to  contend  with  the  cares 
and  privations  of  a  miserable  home,  and  the  common  necessaries  of  life  are 
not  to  be  obtained.  Hunger  and  fatigue  are  followed  by  sleeplessness,  and 
the  various  causes  of  nerve  starvation  invite  the  malady,  or  set  light  to  a 
pre-existing  local  distress. 

A  northeast  wind,  or  a  cold  harsh  day,  will  frequently  invite  an  attack  of 
neuralgic  headache  in  those  persons  who  are  subject  to  it. 

With  regard  to  decayed  teeth  as  a  cause  of  nenralgia,  it  is  important  that 
they  be  not  hastily  removed.  Many  young  persons  have  had  tooth  after 
tooth  extracted,  and  still  the  pain  has  continued.  I  remember  a  nervous 
and  delicate  young  lady,  twenty  3'ears  of  age,  who,  having  lost  three  teeth 
at  the  hands  of  a  dentist,  and  finding  the  neuralgia  of  the  head  and  face  as 
bad  as  ever,  gave  up  the  idea  of  ever  submitting  again  to  a  similar  operation. 
She  took  quinine,  arsenic,  and  cod-liver  oil,  and  the  pain  gradually  left  her, 
notwithstanding  she  had  many  stumps  and  carious  teeth.  For  months 
together  she  was  free  from  all  pain ;  but  it  returned  from  time  to  time  when 
the  health  was  lowered,  and  again  yielded  to  the  same  measures.  ''There 
are  plenty  of  facts  which  suggest  that  lesions  of  nerves  not  necessarily  painful 
may  become  so  from  causes  originally  by  no  means  local.  Thus,  I  believe 
that  there  are  hundreds  of  people  walking  about  London  this  minute,  the 
diseased  nerves  of  whose  carious  teeth  would  be  speedily  roused  into  severe 
neuralgia  by  two  or  three  nights  of  sleepless  watching  and  anxiety,  or  by 
two  or  three  days  of  insufficient  nourishment  or  of  violent  and  exhausting 
exertion  of  mind  or  body.  And,  conversely,  I  am  sure  that  a  generous  diet 
would  often  relieve  the  agony  arising  from  sheer  involvement  of  nerves  in  a 
cancerous  deposit,  "f 

When  a  person  who  has  a  solitary  decayed  tooth  is  suffering  from  contin- 
uous neuralgia  of  recent  duration,  and  the  general  health  is  not  reduced,  I 
should  advise  its  extraction,  if  constitutional  remedies  have  failed.  In  most 
cases  this  will  be  found  a  good  rule  to  carry  out  ]  but  if  there  are  several  de- 
cayed teeth,  and  the  patient  is  weak  and  delicate,  then  I  should  prescribe 
rest,  good  diet,  and  nervine  tonics,  and  trust  to  the  dentist's  powers  of  ar- 
resting further  decay.  Women  who  stand  for  hours  together  over  a  wash- 
tub,  or  a  laundress's  table,  are  frequent  victims  to  this  form  of  headache. 
Household  servants,  who  work  hard  and  are  over-anxious  to  discharge  their 
duties  creditably,  are  sometimes  great  sufferers.     In  confirmed  cases,  if  the 

*See  Chapter  XVI,  on  Neuralgic  Headache  in  Children. 

f  Dr.  Brinton,  on  Anomalous  Intussusception  of  the  Intestines,  in  Lancet,  April  11,  1863, 
p.  411.     Quoted  from  Dr.  Handfield  Jones,  on  Functional  Nervous  Disorders,  1870,  p.  499. 


no  HEADACHES. 

general  health  is  much  impaired,  the  hours  of  labor  must  be  diminished,  or 
there  will  be  no  prospect  of  recovery ;  indeed,  in  many  instances  the  situa- 
tion has  to  be  given  up,  and  pure  air  and  complete  rest  obtained.  The  fol- 
lowing is  a  case  in  illustration  : 

M.  A.  S.,  set.  33,  s.,  a  female  servant,  and  a  resident  in  London,  con- 
sulted me  May  2 2d,  1877.  She  has  been  subject  to  sick  headache  all  her 
life,  but  has  become  much  worse  during  the  last  nine  months,  which  she  at- 
tributes to  hard  work  and  fatigue ;  extra  work  increases  the  pain,  and  going 
up-stairs  tires  her  exceedingly.  The  house  iu  which  she  resides  has  been 
much  altered  in  its  arrangements,  and  this  vexes  and  worries  her. 

History  and  Present  Condition. — The  patient  is  thin  and  weak,  and  bears 
all  the  evidences  of  a  nervous  temperament.  Never  had  any  illness  except 
indigestion  two  years  ago,  which  lasted  six  weeks.  Catamenia  regular,  but 
scanty  ;  slight  leucorrhcea ;  bowels  regular ;  appetite  capricious,  sometimes 
ravenous  ;  has  slept  badly  of  late.  Her  mother  suffered  periodically  from 
headache. 

The  patient's  early  headaches  were  always  relieved  by  sleep,  and  if  she 
could  get  a  nap  she  was  certain  to  be  better,  or  if  she  went  to  bed  a  good 
night's  rest  would  set  her  up.  Now  she  cannot  trust  herself  to  go  out  any- 
where, and  she  is  afraid  of  returning  with  the  pain.  She  feels  very^  low- 
spirited  with  it,  but  not  hysterical,  and  is  inclined  to  shut  herself  up*  and 
keep  quiet. 

Character  of  Headache. — The  situation  of  the  pain  is  entirely  unilateral ; 
it  begins  over  the  right  eye,  above  the  brow,  as  a  heavy  pressure,  which 
works  through  the  centre  of  the  right  half  of  the  brain  to  the  occiput  (one- 
half  of  head),  the  neck  becomes  stiff,  and  there  is  difficulty  in  rotating  the 
head;  then  the  pain  extends  down  the  right  arm,  and  the  fingers  of  the 
same  side  feel  stiff,  and  the  right  leg  is  weak,  as  if  asleep.  She  is  very 
flushed  when  the  pain  is  on  her,  and  the  right  eye  is  red,  injected,  and 
watery,  and  the  lower  eyelid  is  rather  puffed  and  quivering.  Sometimes  she 
feels  irritable  before  the  pain  comes  on,  and  nothing  goes  right.  The  im- 
pulse of  the  heart  against  the  sternum  is  weak,  sudden,  and  short,  and  the 
first  sound  is  rather  blowing,  as  in  ansemic  states  of  the  blood ;  the  least  ex- 
citement causes  palpitation  and  discomfort  over  the  praecordial  region,  while 
she  experiences  feelings  of  breathlessness  and  anxiety  ;  the  pulse  is  weak  and 
tremulous,  and  the  hands  and  feet  are  inclined  to  be  cold. 

She  was  ordered  cocoa  instead  of  tea,  and  to  take  as  much  milk  as  she 
could  digest.  White  fish,  fowl,  and  mutton  were  to  be  the  chief  forms  of 
food  ;  pastry  and  stimulants  were  rigorously  forbidden.  In  the  shape  of 
medicine,  pil.  aloes  et  assafoetid.,  gr.  x,  in  pil.  ij,  at  bedtime,  were  prescribed 
occasionally.  Bromide  of  potassium  and  ammonia  when  the  attacks  of 
headache  threatened  (^Form.  26),  and  a  mixture  of  iron  and  arsenic  twice  a 
day  (Form.  24  F). 

May  29th.  On  the  two  days  following  her  visit  she  had  severe  headache, 
but  the  last  three  days  she  has  been  easier,  and  has  slept  better  ;  the  right 
eyelid  is  puffed  to-day,  and  there  is  pain  over  the  orbit,  from  the  corner  of 
the  nose  to  the  temple  of  the  same  side.  She  has  some  difficulty  in  walking 
up  and  down  stairs;  both  the  right  leg  and  right  hand  are  cold,  stiff,  painful, 
and  rather  swelled ;  but  she  is  on  the  whole  better,  though  nervous  about  her 
state. 

August  2d.  The  queer  sensation  in  her  right  hand  and  leg  has  departed 
for  three  weeks,  and  she  has  had  no  headache  whatever  for  five  v/eeks.  She 
can  take  a  long  walk  Avithout  any  fatigue,  and  she  looks  quite  well.  She  has 
taken  the  arsenic  and  iron  mixture  twice  a  day  since  it  was  prescribed,  and 


NEURALGIC  HEADACHE.  Ill 

a  pill  occasionally.     The  right  eye  is  still  puffed,  and  pain  will  always  bring 
on  this  oedematous  condition. 

In  September  the  patient  had  gained  flesh  and  strength,  and  there  was  no 
return  of  the  headache.  She  was  in  all  respects  well,  and  the  recovery  was 
due  to  her  better  nutrition,  and  improved  quality  of  blood. 

Neuralgia  points  to  a  lowered  state  of  vitality  in  the  track  of  a  nerve,  and 
to  combat  this  nutrition  must  be  improved.  Dr.  Anstie  thus  gives  his  own 
personal  experience  : 

"I  have  been  subject,  ever  since  childhood,  to  severe  attacks  of  neuralgia 
of  the  brow,  entirely  independent  of  digestive  derangement ;  although  liable, 
as  this  affection  usually  is,  to  be  aggravated  by  any  coincident  stomach 
disorder.*  The  pain  always  follows  accurately  the  course  of  those  branches 
of  the  fifth  nerve  which  are  distributed  to  the  forehead,  the  internal  angle  of 
the  eye,  and  the  nose,  more  rarely  extending  also  to  the  branches  derived 
from  the  second  division  of  the  fifth  nerve,  and  distributed  to  the  cheek, 
hit  always  on  the  right  side  only.  This  kind  of  headache  began  to  trouble 
me  at  about  the  age  of  fourteen,  and  for  two  or  three  years  was  of  frequent 
occurrence;  for  many  years  past,  however,  it  has  been  an  unfrequent  visitor. 
One  circumstance  ought  to  be  mentioned,  although  I  cannot  pretend  to 
estimate  its  exact  relation  to  the  production  of  the  neuralgic  pain,  viz.,  that 
about*  the  time  when  the  headache  first  occurred  with  any  severity  I  began 
to  suffer  from  an  obstruction  of  the  lachrymal  duct  on  the  same  side.  This 
obstruction  has  been  ascertained  to  depend  upon  a  light  stricture  of  the 
upper  end  of  the  nasal  duct,  close  to  the  lachrymal  sac,  and  is  apparently 
caused  by  a  tough  fibrous  cicatrix,  probably  the  relic  of  some  past  ulceration. 
Treatment  by  the  passing  of  metallic  probes  has  been  adopted  from  time  to 
time,  with  great  temporary  relief,  but  the  obstruction  has  always  recurred, 
and,  as  a  consequence  of  it,  the  discharge  of  tears  from  the  gland  is  incon- 
tinently profuse.  The  attacks  of  pain  are  invariably  caused  by  fatigue  of 
body  or  mind,  and  are  preceded  and  accompanied  by  pallor  of  the  face, 
weak  pulse,  and  a  general  sense  of  depression.  The  only  remedies  which 
are  of  the  slightest",value  are  sal  volatile,  hot  tea,  and  occasionally  quinine  in 
a  full  dose,  or  a  glass  of  wine.  Ammonia  and  hot  tea  are  most  frequently 
useful,  "f 

The  condition  of  the  renal  organs  has  much  to  do  with  headache,  and  I 
have  seen  very  persistent  forms  of  it  (see  page  87,  Uraemic  Headache), 
when  the  kidneys  have  sustained  mischief  from  scarlet  fever  and  desquama- 
tive nephritis.  The  cases  I  have  generally  observed  have  been  marked  by 
continuous  frontal  headache,  heavy  and  oppressive,  less  at  one  time  than  at 
another,  but  rarely  if  ever  completely  absent  for  a  single  moment.  Dr. 
Barthels  has  witnessed  severe  hemicrania  in  connection  with  renal  cirrhosis, 
and  I  shall  therefore  quote  his  own  words  on  the  subject.  "In  other  cases, 
the  first  evidence  of  the  disease  consists  in  frequent  and  severe  attacks  of 
headache,  sometimes  occurring  under  the  form  of  excessively  severe  hemi- 
crania of  remarkably  long  duration;  indeed,  I  have  observed  this  form  a 
number  of  times.  The  pain,  too,  may  extend  down  the  neck,  and  even  to 
the  brachial  plexus  of  the  affected  side.  Such  paroxysms  may  last  for  several 
days.  In  one  case  of  this  kind  I  noticed  almost  complete  anaesthesia  of  the 
skin  of  the  face  and  of  the  fingers  upon  the  affected  side  during  the  continu- 

*A  neuralgic  headache  is  sometimes  caused  by  gastric  irritation  and  acidity,  and  a  full 
dose  of  an  alkali,  as  half  a  teaspoonful  of  bicarbonate  of  potash  in  a  wineglassful  of  water, 
will  liberate  carbonic  acid  in  the  stomach,  and  speedily  remove  the  pain. 

f  On  Stimulants  and  Narcotics,  by  F.  E.  Anstie,  M.  D.,  1864,  p.  83,  Philadelphia, 
Blakiston. 


112  HEADACHES. 

ance  of  the  attack.  This  patient  had  an  attack  of  the  kind  nearly  every 
week;  and,  finally,  during  the  intermissions,  normal  sensation  did  not  quite 
return  to  the  face  or  fingers,  but  a  feeling  of  numbness  and  formication  re- 
mained. 

"In  any  case  of  migraine  occurring  after  middle  life  in  an  apparently 
robust  individual,  it  is  well  to  consider  the  possibility  of  the  nerve  affection 
being  dependent  upon  contracting  kidneys.  Neuralgic  pains  in  the  track  of 
other  nerves  have,  in  my  own  experience,  proved  far  less  common  than 
headache,  so  that  I  am  still  doubtful  whether  I  can  properly  connect  these 
isolated  attacks  of  neuralgia  with  this  renal  disease  as  cause  and  effect.  But 
the  terrible  itching  of  the  skin,  which  I  shall  advert  to  hereafter,  may  be 
reckoned  belongs  indisputably  among  the  results  of  the  renal  affection,  and 
it  is  likely  enough  that  a  more  or  less  extensive  muscular  pain  that  sets  in 
toward  the  end  of  life,  and  is  usually  satisfactorily  but  fancifully  explained 
under  the  name  of  rheumatism,  owns  a  similar  origin."* 

Treatment. — The  subjects  of  this  variety  of  headache  being  usually  anaemic, 
the  first  indications  are  to  improve  the  general  conditions  by  nutritious  diet, 
and  enforcing  mental  and  bodily  rest.  I  have  known  a  full  dose  of  brandy 
and  water  give  almost  im.mediate  relief  when  the  attack  was  limited  to  one 
side  of  the  head  and  face.  A  lady  who  was  under  my  care  some  years  ago 
was  able  to  ward  off  a  neuralgic  headache,  which  came  on  late  at  night,  by 
taking  a  slice  of  bread  and  butter,  and  a  glass  of  Bass's  ale,  or  good  bitter 
beer,  before  getting  into  bed.  A  local  stimulant  of  chloroform  and  aconite 
liniment  will  sometimes  give  ease  after  friction  for  a  few  minutes.  A  little 
extract  of  belladonna  rubbed  into  the  affected  temple  will  be  useful  in  some 
cases  (Form,  no),  and  an  ointment  of  aconitina  (Form.  113)  or  of  veratria 
(Form,  in)  will  prove  efficacious  in  some  obstinate  cases.  Internally,  the 
carbonate  of  ammonia  will  sometimes  be  of  service  (Form.  16).  The  chlo- 
ride of  ammonium  is  another  good  remedy  in  these  cases,  particularly  if  the 
pain  extends  to  the  face  (facial  neuralgia).  It  should  be  given  in  9j  or  gss. 
doses  (Form.  27),  and  if  no  relief  follow  the  administration  of  three  or  four 
doses,  it  is  not  Avell  to  continue  it.  It  diminishes  congestion  of  the  vessels, 
and  promotes  cutaneous  action  and  diaphoresis. 

When  the  pain  is  very  severe  the  hypodermic  injection  of  morphia  (gr.^) 
may  be  tried,  and  it  is  necessary  to  conduct  the  operation  carefully,  as  trou- 
blesome boils,  and  even  sloughing,  may  follow ;  and  on  this  account  I 
should  be  reluctant  to  employ  it  for  the  face. 

The  hypophosphite  of  soda  in  infusion  of  calumba  (Form.  28)  is  a  good 
remedy,  or  the  hypophosphoric  acid  may  be  given  in  combination  with  qui- 
nine, strychnia  and  iron  (Form  21-22-22  a-23). 

Arsenic  is  a  remedy  of  the  greatest  possible  value,  if  it  is  given  judiciously 
and  watched  carefully;  but  it  is  too  generally  abandoned  on  the  first  symp- 
toms of  constitutional  irritation  becoming  manifest,  and  when  its  alterative 
effects  on  the  blood  are  about  to  be  secured  (Form.  8-9).  Under  these  cir- 
cumstances it  should  be  discontinued  for  a  time,  and  then  resumed  again. 
It  is  well  to  be  acquainted  with  the  physiological  signs  of  arsenical  action, 
for  the  exhibition  of  small  doses  in  some  persons  of  peculiar  idiosyncrasy  is 
accompanied  with  so  much  nausea  and  depression,  as  to  render  the  contin- 
uance of  the  remedy  unadvisable. 

"I  have  witnessed  the  postponement  and  ultimate  cessation  of  a  periodic 

*  Cyclopoedia  of  ]Medicine,  by  Dr.  H.  von  Ziemssen,  Diseases  of  Kidneys,  vol.  xv.,  p. 
421. 


NEURALGIC    HEADACHE.  I  I  3 

headache  through  the  influence  of  arsenic  before  the  pricking  eyelid  or  sil- 
vered tongue  demonstrated  its  agency."* 

When  we  are  disappointed  with  the  effects  of  arsenic,  there  is  often  a  taint 
of  gout,  or  syphilis,  or  mercury,  and  when  combined  according  to  these 
circumstances  we  may  often  succeed.  "We  are  called  to  one  laboring 
under  excruciating  headache,  which  attacks  him  at  an  early  hour  in  the 
day,  and  regularly  takes  its  departure  in  the  afternoon.  Day  after  day  the 
attack  is  renewed,  and  the  same  hours  witness  the  return  and  departure  of 
the  paroxysm.  It  has  defied  all  ordinary  methods  of  treating  headache; 
the  physician  has  pronounced  it  brow  ague,  and  has  promised  that  it  shall 
yield  to  quinine  or  bebeerin.  He  is  disappointed;  it  has  resisted  both;  he 
betakes  himself  to  Fowler's  solution,  and  after  two  or  three  days  the  attack 
is  postponed,  or  it  comes  in  a  less  severe  form,  and  takes  its  leave  at  an 
earlier  hour.  After  another  day  or  two  it  ceases  altogether.  We  are  grati- 
fied by  this  exhibition  of  the  power  of  arsenic  over  periodic  headache,  and 
resolve  to  test  it  again  on  the  first  opportunity.  The  occasion  arrives;  with 
confidence  we  prescribe  our  remedy ;  we  persist  day  after  day  in  its  use,  but 
we  are  doomed  to  disappointment.  We  return  to  quinine,  which  has  sel- 
dom failed  on  former  occasions,  but  without  success.  We  betake  ourselves 
to  bebeerin,  and  supplement  its  powers  with  the  alternative  efi''ects  of  depur- 
ants,  diuretics  and  laxatives,  but  all  to  no  avail.  We  try  a  combination  of 
arsenic  and  quinine,  and  in  a  short  time  the  wished-for  cure  is  obtained,  "f 

It  is  well  to  bear  in  mind  that  neuralgic  headache  sometimes  occurs  in 
plethoric-looking  persons  ;  but  they  have  not  the  blood  belonging  to  this 
condition,  and  the  florid  countenance  is  more  strictly  due  to  relaxation  and 
debility  of  the  capillary  circulation.  In  subjects  of  this  kind  I  have  found 
a  mixture  of  sulphate  of  magnesia  and  quinine  useful  till  the  liver  and  por- 
tal circulation  have  been  drained  (Form.  29).  After  this,  full  doses  of  qui- 
nine, and  a  little  brandy  and  water  during  the  day,  have  aided  the  cure. 
Such  persons  have  gone  on  comfortably  for  weeks  and  months,  notwith- 
standing inattention  to  decayed  teeth,  and  a  drain  from  the  system  of  var- 
ious kinds. 

When  the  subjects  are  excitable  and  hysterical,  and  the  pain  is  persistent, 
bromide  of  ammonium  or  potassium  with  valerian  will  be  advisable  (Form. 
72),  and  if  anaemia  is  a  marked  symptom,  iron  with  quinine  (Form  20  to 
24),  or  valerianate  of  zinc  and  a  stomachic  (Form.  87);  phosphorus  and 
small  doses  of  strychnia,  if  the  nervous  system  is  harassed  by  mental  toil 
and  anxiety  (Form  88-89).  If  there  is  sleeplessness,  a  pill  of  camphor, 
henbane,  and  cannabis  indica  (Form.  92-93)  will  be  found  of  service,  and 
it  will  have  a  most  tranquilizing  effect ;  but  all  drugs  will  fail  to  remove  the 
pain,  unless  air,  exercise,  rest,  and  good  food  be  prescribed. 

Gelseminum  sempervirens  has  been  employed  successfully  in  neuralgic 
affections,  and  the  neuralgia  arising  from  decayed  teeth.  In  hemicrania  and 
supraorbital  neuralgia  it  has  been  found  exceedingly  useful,  but  at  present 
it  is  impossible  to  say  what  those  cases  are  which  will  be  most  benefited  by 
it.  The  powder  and  the  tincture  are  the  two  forms  for  administration  ;  the 
dose  of  the  former  is  from  one  to  two  grains,  and  of  the  latter  from  ten  to 
twenty  minims.  In  the  case  of  a  lady,  set.  39,  I  found  that  one  grain  of 
the  powder  made  into  a  pill  with  glycerin  and  given  every  night  at  bedtime 
acted  marvelously,  inducing  sleep,  and  warding  off  a  paroxysm  when  taken 

*0n  the  Physiological  and  Therapeutical  Effects  of  Arsenic,  by  James  Begbie,  M.  D., 
1862,  p.  272. 

■j-  Ibid.,  p.  276. 


114  HEADACHES. 

as  the  seizure  was  threatening.  In  large  doses  it  appears  to  cause  frontal 
headache,  contraction  of  the  pupils,  and  weakness  of  the  legs.*  From  the 
observations  of  M.  Emery-Heroguelle  it  acts  favorably  as  an  anti-neuralgic 
in  neuralgia  of  the  fifth  pair,  dental  neuralgia,  the  brachial  plexus  and  inter- 
costal nerves,  f 

Croton  chloral  has  been  recommended  by  Dr.  Liebreich,  of  Berlin,  as 
possessing  a  special  action  on  the  sensory  branches  of  the  fifth  nerve.  It  is 
of  most  benefit  in  facial  neuralgia,  relieving  pain  and  producing  sleep.  I 
have  known  it  prove  very  serviceable  in  some  cases  of  nervous  headache  in 
which  the  disorder  has  chiefly  occupied  one  temple,  the  occiput  and  neck, 
or  one- parietal  bone,  and  in  other  cases  not  only  to  utterly  fail,  but  to  in- 
duce sickness  and  nausea  if  they  did  not  previously  exist.  I  generally  give 
gr.  X.  for  a  dose  in  plain  water,  though  it  has  been  advised  to  dissolve  the 
remedy  in  a  few  drops  of  glycerin,  and  then  add  the  required  quantity  of 
cinnamon-water,  which  to  some  extent  disguises  the  bitter,  nauseous  taste. 
On  this  account  it  may  be  given  in  the  form  of  a  pill,  beginning  with  two 
grains,  and  increasing  the  dose  according  to  the  urgency  of  the  symptoms. 

I  have  known  terrible  neuralgia  over  one  eye  and  side  of  the  face  follow 
immediately  on  a  diffused  nervous  headache.  There  has  been  sickness  and 
prostration.  A  teaspoonful  of  brandy  in  a  little  soda-water,  and  quinine 
with  spirits  of  chloroform  (Form.  12),  have  been  retained  on  the  stomach, 
and  the  pain  has  gradually  departed.  Twenty  grains  of  bromide  of  potas- 
sium in  a  wineglassful  of  water  will  sometimes  have  the  same  beneficial  effect. 

A  middle-aged  lady,  recently  under  my  care,  derived  great  benefit,  and 
repeatedly  warded  off  an  attack  of  neuralgic  headache,  by  taking,  as  soon 
as  she  awoke  in  the  morning,  one  or  two  teaspoonfuls  of  tincture  of  quinia 
in  a  small  cup  of  milk. 

In  the  intervals  of  the  headache  remedies  must  be  employed  for  improv- 
ing the  quality  of  the  blood,  and  restoring  the  general  health.  Quinine 
and  arsenic  together  are  very  valuable  remedies  (Form.  8-9),  and  so  are 
cod-liver  oil  and  fatty  matters  for  restoring  the  wasted  nervous  tissues. 

*"A  girl  nine  years  old  was  killed  in  two  hours  by  a  dose  of  two  drachms  of  the  tincture." 
— Squire' s  Pharmacopaeia,  iithedit.,  1877,  p.  '^\^- 
f  Medical  Examiner,  Dec.  27th,  1877,  p.  1067, 


CHAPTER   XVI. 

HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE. 

Preliminary  Remarks  on  the  Significance  of  Headache  in  Children — Their  Insidious  Course 
and  Character — Hereditary  Disease — The  Resemblance  in  Physical  Form  and  Features 
to  the  Parent  are  not  more  Constant  than  Mental  Peculiarities — Importance  of  Checking 
the  Transmission  of  Disease — The  Life  of  Childhood  Contrasted  with  that  of  the  Adult 
— Brain  of  Childhood  compared  to  that  of  Maturity — Mental  Development  compared 
with  Physical  Growth — Their  Relationship  and  Bearing  on  Health — Effects  of  Illness  on 
the  Functions  of  the  Brain — Parents  entail  Disastrous  Evils  on  their  Offspring  by  Forced 
Mental  Discipline — Difference  among  Children  in  the  Power  of  Memory,  and  Acquire- 
ment of  Knowledge — Case  of  Arithmetical  Power  related  by  Carpenter — Evil  Conse- 
quences of  the  Forcing  System — Hypertrophy  of  the  Brain — School  Board  Legislation — 
Weight  and  Size  of  the  Human  Brain  at  Different  Ages  in  Both  Sexes — Popular  Tradi- 
tion of  Delayed  Mental  Training — Professor  Lay  cock's  Opinion  that  Precocious  Children 
are  generally  Strumous. 

The  Chief  Varieties  of  Headache  in  Children  :  i.  Cerebral  Headache.  2.  Gastric  Head- 
ache. 3.  Epileptic  Headache.  4.  Febrile  Headache.  5.  Headache  from  Anaemia, 
Neuralgia,  etc.,  constituting  Nervous  Headache.  6.  Headache  depending  on  some  In- 
tricate Change  in  the  Cerebral  Membranes  or  Tissues  of  the  Brain.  7.  Organic  Head- 
ache. 

Headaches  hold  such  a  prominent  position  in  the  diseases  of  childhood 
as  to  constitute  them  worthy  of  special  notice  and  consideration.  There 
are  few  practitioners  of  any  experience  who  have  not  had  reason  to  lament 
the  overlooking  of  the  first  symptoms  of  brain  mischief  in  a  young  child. 
No  fever,  no  vomiting,  no  thirst,  may  have  been  present  to  arrest  attention; 
the  symptoms  may  have  been  entirely  subjective,  and  yet  in  a  few  hours  the 
child  has  been  struck  down  by  a  convulsion,  and  forthwith  meningitis  has 
followed.  •  No  parent  should  neglect  a  headache  in  any  child  under  thirteen 
or  fourteen  years  of  age,  especially  in  girls  about  this  period  of  life,  when 
physiological  changes  are  in  active  progress. 

The  conventional  usages  of  modern  life,  in  regulating  the  education  of 
children,  have  a  tendency  to  push  them  forward  without  sufficient  regard  to 
physical  training,  the  acquisition  of  knowledge  being  considered  of  more 
iBoment  than  the  vigorous  growth  of  the  body  and  the  stability  of  the  frame. 
The  influences  which  develop  the  general  strength,  and  produce  strong  mus- 
cles and  sound  limbs,  are  counteracted  in  their  good  effects  by  the  undue 
pressure  which  is  put  upon  the  brain  when  it  is  least  able  to  bear  the  tension, 
and  nature  is  thus  thwarted,  and  her  wise  counsels  are  defiantly  ignored  and 
set  aside.  "  No  perfect  brain  ever  crowns  an  imperfectly  developed  body. 
When  Michael  Angelo  reared  St.  Peter's  dome  in  the  air,  he  made  every 
stone  beneath  contribute,  not  only  to  the  use  and  beauty  of  the  part  he  put 
it  in,  but  to  the  support  and  power  of  the  dome.  The  brain  must  be  built 
up  in  connection  with  the  building  of  the  rest  of  the  body,  remembering 
constantly  that  the  imperfections  of  the  latter  reflect  themselves  upon  the 
former."* 

Parents  incur  a  heavy  responsibility  in  enforcing  a  course  of  study,  or  a 
system  of  training,  which  is  likely  to  induce  disorders  from  which  they  suf- 
fer themselves.     The  resemblance  which  a  child  bears  to  the  parent  in  out- 

*The  Building  of  a  Brain,  by  E.  H.  Clarke,  M.  D.,  1875,  P-  21. 


Il6  HEADACHES. 

ward  form  and  feature,  ought  to  teach  us  how  transmissible  is  every  taint 
and  peculiarity,  which  it  should  be  our  constant  desire  to  avoid  and  to 
arrest.  Some  faulty  conditions  of  the  blood,  and  of  the  different  fluids  of 
the  body,  may  be  nearly  stamped  out  by  careful  regimen  and  appropriate 
management,  as  we  have  seen  exemplified  in  some  members  of  a  family  who 
have  been  reared  differently  to  the  rest.  But  asthma,  emphysema,  the  heem- 
orrhagic  diathesis,  tuberculous  diseases,  cancer,  gout,  and  affections  of  the 
skin,  have  a  congential  origin,  and  here  structural  disease  is  as  frequently 
owing  to  a  transmitted  tendency^  and  to  a  peculiar  state  of  the  blood  and 
bodily  temperament,  as  the  family  outline  of  the  figure  and  face.  When 
we  consider  the  disorders  of  the  brain  and  nervous  system,  there  are  few 
sensible  parents  who  will  not  admit  that  headache  is  an  affection  more  fre- 
quently hereditary  than  almost  any  other.  The  nervous  habits,  and  the  ex- 
citable manner  of  the  parents,  stand  out  in  a  remarkable  manner  where  the 
children  even  have  been  brought  up  at  a  distance  from  home,  and  when 
their  surroundings  have  been  entirely  changed.  "  There  is  much  that  is 
curious  in  the  tendency  to  headaches  thus  transmitted  by  descent,  and  often 
going  through  whole  families  with  similar  character.  The  causes  here  pre- 
sumably vary  in  different  instances.  Sometimes,  and  especially  perhaps 
where  they  are  periodical,  the  affection  may  belong  to  the  gouty  habit,  and 
to  the  matter  of  gout  in  the  circulation.  In  other  cases  abnormal  structure 
of  the  vessels  of  the  head  may  be  concerned  ;  in  others,  again,  some  peculi- 
arity in  the  nervous  system  itself."  *  These  considerations  should  counsel 
prudence,  and  control  the  agencies  at  work  which  threaten  domestic  peace. 
Surely  the  cautious  parent  ought  to  consider  the  cheerful  or  melancholy  tem- 
perament of  his  child,  his  mental  as  well  as  his  bodily  strength,  and  be 
guided  in  his  management  accordingly.  The  gains  and  losses  in  life,  the 
competition  and  the  struggles,  should  not  be  obtrusively  thrust  before  him, 
for  the  mind  will  realize  early  enough  the  bitter  lessons  of  material  exist- 
ence. How  different  is  the  life  of  childhood  from  that  of  the  adult !  It  is 
the  existence,  as  it  were,  of  another  creation  ;  life  is  wrapt  up  in  the  present, 
and  not  in  the  future.f  A  child  lives  for  himself,  and  not  for  others;  his 
keen  sensibilities  move  him  to  sorrow  and  to  pain  with  great  quickness ;  his 
weak  reasoning  power  is  counteracted  by  the  activity  of  his  imagination. 
He  feels  intuitively  the  approach  of  a  friend,  and  knows  his  foe  in  an  in- 
stant. His  life  is  not  one  of  mingled  sorrow  and  pleasure ;  it  is  all  one,  or 
it  is  all  the  other — the  past  lights  up  no  remorse,  the  future  has  no  sorrow- 
ful forebodings.  How  fruitful  of  evil  is  the  tyrannical  oppression  of  the 
unsympathizing  parent  or  guardian  of  a  child,  who  exacts  from  him  thought 
and  conduct  beyond  his  years,  and,  with  restless  caprice,  despotically  moulds 
his  actions. 

The  weakening  more  and  more  of  the  overtaxed  brain  lays  the  foundation 
of  nerve-exhaustion,  and  disorders  are  induced  which  years  may  never  over- 
come, even  if  the  defective  nutrition  of  the  brain  does  not  lead  to  those 
pathological  changes  which  affect  the  blood-vessels  and  cerebral  cells.  The 
symptoms  which  announce  these  alarming  evils  are  fits  of  recurring  mental 
excitement,  evidencing  exhaustion  in  the  functions  of  the  brain.  The 
amount  of  exercise  which  ordinarily  maintains  this  organ  in  health  now  im- 
pedes the  harmony  of  its  actions,  and  henceforth  invites  those  changes, 

*  Medical  Notes  and  Reflections,  Hereditary  Disease,  by  Sir  H.  Holland,  Bart.,  M.  D., 
F.  R.  S.,    i8S5,p.  37. 

I  "  Children  are  heedless  alike  of  the  past  and  the  future ;  the  present  is  enough  for  them." 
— La  Bruyere. 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE.  11/ 

which  the  naked  eye  too  plainly  detects  in   some   cases,  while   scientific 
methods  of  research  are  alone  capable  of  revealing  them  in  others. 

If,  in  ignorance  of  ensuing  evil,  children  are  pushed  forward  too  much, 
fretfulness  of  mind  is  implanted,  and  general  debility  takes  the  firmest  hold 
of  their  constitutions  in  the  springtide  of  life.  When  a  child  is  fast  growing 
it  needs  fostering  care,  and  all  its  reserve  of  energy,  in  order  to  approach 
completeness  of  development.  If  at  this  time  it  sustains  damage,  or  injury 
of  any  kind,  and  one  link  is  broken  in  that  mysterious  chain  of  vital  forces 
which  keeps  the  whole  fabric  in  order,  then  the  health  in  too  many  instances 
is  appreciably  undermined,  and  life  is  absolutely  shortened.  A  closely  de- 
fined plan  of  study  carried  out  in  defiance  of  the  laws  of  health  often  leads 
to  a  delicate  manhood.  "  Study  and  student- work  aid  this  evolution;  but, 
as  we  have  seen,  they  are  not  the  only  factors  of  brain-building.  Cerebra- 
tion is  brain-exercise  ;  and  brain-exercise  strengthens  and  develops  the 
brain.  But  the  brain  is  evolved  from  the  organization,  and,  unless  the  lat- 
ter is  normal,  the  evolution  is  imperfect.  Moreover,  physiology  informs  us 
that  conscious,  or,  more  properly  speaking,  volitional  cerebration,  should 
not  be  attempted  too  early  in  life.  In  nature's  order,  the  nervous  system  of 
an  individual  is  the  last  to  attain  its  full  development ;  and,  of  the  nervous 
system,  the  cerebial  ganglia  reach  maturity  later  than  any  other  part.  Ob- 
viously the  latter  should  not  be  put  to  work  till  they  are  capable  of  labor. 
Without  exercise  an  organ  will  attain  little  or  no  development ;  excessive  or 
premature  exercise  will  monstrously  develop  it — in  either  case  to  the  injury 
of  the  rest  of  the  organism."  *  But  it  is  worthy  of  consideration  that  the 
judicious  culture  (within  appropriate  limits)  of  the  mind  in  early  life,  gives 
the  child  so  trained  an  immense  advantage  over  another  less  fortunate.  He 
retains  more  after  a  lapse  of  time,  because  his  previous  knowledge  calls  up 
something  familiar  and  already  acquired  which  bears  on  the  subject  in  hand. 
This  holds  good  through  life,  and  it  is  only  necessary  to  furnish  him  with 
fresh  facts,  and  new  combinations  and  impressions  will  be  easily  engrafted 
upon  the  recollection.  Every  skilled  workman  from  his  previous  training 
is  rendered  capable  of  acquiring  an  increase  of  knowledge  from  the  resem- 
blance of  the  present  to  the  past,  the  past  coming  back  to  him  when  a  sim- 
ilar subject  is  again  presented  to  his  mind,  however  remote  the  connection 
may  be.  The  power  of  acquiring  knowledge  or  of  forming  habits  is  partic- 
ularly strong  in  childhood,  when  the  mind  is  flexible  and  plastic.  Of  all 
periods  of  life,  then,  this  is  the  one  when  impressions  are  most  likely  to  be- 
come enduring,  and  the  habit  of  concentration  to  be  acquired — a  period 
when  the  capacity  of  the  brain  should  be  carefully  estimated,  and  the  organ 
not  pushed  to  dangerous  excitement,  which  in  the  growing  stage  is  more 
pernicious  than  complete  disuse. 

The  development  of  the  human  brain,  like  the  wonderful  organization  of 
the  whole  animal  kingdom,  is  a  subject  of  peculiar  interest,  proceeding  on 
that  grand  and  harmonious  design  which  the  Almighty  has  instituted  through- 
out the  universe.  If  the  facts  which  spring  from  a  study  of  vital  phenomena 
are  carefully  searched  and  scrutinized,  we  shall  trace  the  connecting  link 
between  the  physical  and  the  intellectual  parts  of  our  nature,  and  be  in  a 
better  position  to  understand  their  mutual  dependence  on  one  another.  In 
the  earliest  periods  of  foetal  existence,  when  life  is  just  beginning  to  dawn, 
there  is  nothing  like  nervous  matter,  those  parts  corresponding  to  the  head 
consisting  of  merely  a  limpid  colorless  fluid.  The  corpora  olivaria  are  not 
formed  till  the  seventh  month,  and  at  the  period  of  birth  the  optic  thalami 

*The  Building  of  a  Brain,  by  E.  H.  Clarke,  M.  D.,  1875,  P-  44- 


1 1 8  HEADACHES. 

and  posterior  ganglia  of  the  cord  are  sunk  amid  the  substance  of  the  hemi- 
spheres (Solly).  The  complicated  structure  of  the  nervous  system  reaches 
perfection  in  the  adult  brain  only. 

An  adult  brain  may  stand  an  excessive  amount  of  overwork  if  the  physical 
strength  is  robust,  but  a  child  cannot  endure  immoderate  exercise  of  the 
mental  powers  without  soon  breaking  down,  unless  there  is  strong  bodily 
health  also.  Even  if  the  attempt  is  made,  failure  is  certain.  We  are  willing 
to  admit  the  force  of  an  argument  held  by  those  philosophers  who  have 
closely' analyzed  the  subtle  powers  of  mind,  and  have  examined  what  it  is 
capable  of  achieving.  It  is  unquestionable  that  the  reasoning  powers  are 
never  completely  developed  if  education  is  neglected  or  imperfect.  The 
y  brain  requires  exercise  or  it  will  waste,  and  the  moral  strength  will  decline 
also  if  intellectual  culture  is  abandoned.  Take  the  case  of  two  members  of 
the  same  family  starting  in  life  with  an  equal  capacity  of  mind.  The 
exercise  of  one  brain,  let  us  suppose,  is  complete  and  methodical,  that  of  the 
other  is  entirely  neglected.  The  first  youth  will  grow  up  strong  and  vigorous 
"^in  intellect,  and  be  anxious  to  carry  out  with  justice  and  honor  the  re- 
sponsibilities of  his  situation  ;  whilst  the  actions  of  the  other  are  governed  by 
V  selfish  and  ungenerous  motives,  or  the  ruling  principle  of  his  life  is  caprice. 
No  human  being  is  so  constituted  as  to  be  above  physical  considerations; 
the  closeness  of  the  connection  must  be  apparent  to  all  who  reflect  on  the 
question  for  a  single  moment.  The  brain  of  a  person  whose  bodily  health 
is  hereditarily  weak,  or  who  has  been  subjected  to  depressing  influences,  will 
evince  earlier  and  greater  indications  of  weariness  than  it  would  do  if  the 
physical  conditions  had  been  different,  and  the  brain  supplied  with  healthy 
blood.*  Can  a  child  who  has  recovered  from  fever,  or  an  exhausting  illness, 
prosecute  his  studies  at  once  with  the  same  delight  and  ease  he  did  before 
the  attack?  A  considerable  length  of  time  must  elapse  before  his  digestive 
system  is  strong  enough  to  assimilate  sufficient  nourishment  to  restore  the 
exhausted  energies  of  the  brain.  We  know  his  mental  condition  as  he  ap- 
proaches convalescence.  He  wakes  in  the  morning  after  refreshing  sleep, 
and  is  lively  with  his  toys  and  amusements;  then  suddenly  he  becomes 
petulant  and  irritable  over  them,  throwing  them  on  one  side  in  anger  and 
disgust,  till  he  falls  off  to  sleep,  and  the  jaded  brain  is  restored.  The  men-^ 
tal  faculties  have  sustained  a  shock  by  the  illness,  and  the  disease  has  im- 
paired or  temporarily  suspended  the  powers  of  memory,  and  obliterated 
recent  impressions.  What  he  does  acquire  is  easily  forgotten,  till  the  brain 
is  restored  to  its  former  strength.  Some  years  ago  I  had  under  my  care  a 
little  boy,  aged  two  years,  who  recovered  from  meningitis  after  many 
months  of  shattered  health.  When  he  reached  the  age  of  seven,  and  was 
strong  in  his  limbs,  an  attempt  was  made  to  teach  him  to  read  and  write ; 
and  it  was  found  that  he  could  give  his  attention  for  about  ten  minutes  at  a 
time,  and  that  then  he  began  to  tire.  At  first  this  was  ascribed  to  idleness 
and  inattention,  but  it  was  soon  found  that  perseverance  in  the  attempt 
caused  headache,  pallor  of  the  face,  and  disinclination  for  food ;  his  nights 
were  restless,  and  it  was  obvious  that  the  continuance  of  the  plan  would  be 
fraught  with  danger.     His  memory  was  not  retentive,  and  it  was  more  than 

*  "  The  brain  is  clearer  in  \dgorous  health  than  it  can  be  in  the  gloom  and  miseiy  of  sick- 
ness ;  and  although  health  may  last  for  a  while  without  renewal  from  exercise,  so  that  if  you 
are  working  under  pressure  for  a  month  the  time  given  to  exercise  is  so  much  deducted  from 
the  result,  it  is  not  so  for  the  life's  perfonnance.  Health  sustained  for  many  years  is  so  use- 
ful to  the  realization  of  all  considerable  intellectual  undertakings,  that  the  sacrifice  to  the 
bodily  well-being  is  the  best  of  all  possible  investments." — The  Intellectual  Life,  by  P.  G. 
Hamerton,  1873,  P-  28. 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE.  II9 

probable  that  were  the  system  continued  in  years  to  come,  the  brain  would 
never  be  able  to  master  more  than  the  most  ordinary  details  of  elementary 
knowledge.  The  shock  sustained  at  the  time  of  the  illness  had  impaired  the 
cerebral  tissue,  and  damaged  the  mental  powers. 

"Dr.  Pritchard,  on  the  authority  of  the  late  Dr.  Rush,  of  Philadelphia, 
mentions  an  American  student,  a  person  of  considerable  attainments,  who, 
on  recovering  from  a  fever,  was  found  to  have  lost  all  his  acquired  knowl- 
edge." At  length,  when  his  health  was  restored,  "his  lost  impressions 
suddenly  returned  to  his  mind,  and  he  found  himself  at  once  in  possession  of 
all  his  former  acquirements."*  I  have  seen  some  of  the  worst  forms  of 
headache  supervene  on  acute  illness,  and  continue  when  the  attempt  to 
resume  study  was  made.  A  boy  aged  thirteen,  who  had  a  tedious  attack  of 
typhoid  (in  which  the  cerebral  symptoms  were  considerable),  always  suffered 
from  severe  headache  when  he  attempted  to  resume  his  studies ;  and  the  in- 
ference I  drew  from  the  protracted  stupor  and  heaviness  was,  that  the  brain 
tissue  had  undergone  some  permanent  change,  and  that  if  the  course  of  study 
was  continued  after  this  warning,  his  memory  would  be  irretrievably 
damaged,  and  that  he  would  possibly  pass  into  a  state  bordering  on  idiocy. 

The  privation  of  active  exercise  and  light  amusements  for  children,  by 
enfeebling  the  digestive  and  assimilative  functions,  impairs  the  quality  of 
the  blood,  and  thus  disturbs  and  lowers  the  cerebral  functions.  The  ntrv- 
ous  symptoms  shown  in  petulance  and  irritability  should  be  serious  warn- 
ings, though  they  are  too  frequently  overlooked,  or  attributed  to  a  wrong 
cause.  A  headache  traced  to  confinement  and  study  is  a  familiar  example 
of  this  over-cultivation  of  the  intellect,  and  in  every  instance  where  it  arises 
the  studies  should  be  cast  aside  and  recreation  substituted.  Absolute  brain 
repose  is  an  urgent  necessity  in  these  cases,  and  the  greatest  literary  workers 
in  all  times  have  sought  hours  of  indolence  to  recruit  their  exhausted  ener- 
gies, and  win  back  sleep  to  their  worn-out  intellect  and  wearied  body. 
"There  appears  to  be  a  kind  of  sleep  in  which  no  mental  action  whatever 
takes  place,  so  that  the  only  central  organs  in  operation  are  those  of  an 
automatic  and  reflex  nature.  The  functions  depending  upon  the  central 
organs  of  this  character,  viz.,  circulation,  respiration,  secretion,  digestion, 
etc.,  go  on  as  usual. "f 

Moderate  occupation  of  the  mind  is  healthy  and  beneficial ;  excessive 
work  is  nothing  less  than  a  curse.  Both  independent  and  prudential  con- 
siderations impress  us  with  the  conviction  that  no  plausible  reasoning  can 
support  the  views  of  abstruse  thinkers,  who  delude  society  by  the  advocacy 
of  schemes  for  education  which  press  so  hard  upon  the  intellect  of  youth. 
They  indicate  a  grievous  lack  of  capacity  to  comprehend  the  fragility  of  a 
structure  which  is  incapable  of  bearing  any  additional  burden,  when  the 
struggle  to  support  life  alone  is  great,  and  conservative  action  is  urgently 
needed  to  sustain  the  workmanship.  Some  restraint  ought  to  be  placed  on 
the  hazardous  attempts  of  parents  to  force  their  children  in  the  prosecution 
of  intellectual  pursuits,  when  the  mind  betrays  any  symptom  of  fatigue  or 
weariness.  The  common  fault  to  be  laid  at  the  threshold  of  most  ambitious 
people  is  that  they  take  it  for  granted  that  all  their  children  have  equal  nat- 
ural endowments,  and  that  what  the  one  acquires  readily  the  other  can 
equally  well  accomplish.  No  greater  delusion  can  take  possession  of  the 
understanding,  and  parents  should  be  warned  not  to  steer  in  a  direction 
whence  they  may  drift  blindly  into  peril  and  danger.     If  they  calmly  con- 

*  On  the  Intellectual  Powers,  by  J.  Abercrombie,  M.  D. 

I  Hermann's  Human  Physiology,  by  Arthur  Gamgee,  M.  D.,  F.  R.  S.,  1875,  P-  324- 


120  HEADACHES. 

sider  the  advice  not  to  expose  all  their  children  to  the  same  ordeal,  they  will 
avoid  the  current  which  is  carrying  them  only  to  the  ocean  of  sorrow.  One 
child  is  born  with  prodigious  capabilities,  and  the  acquirement  of  knowledge 
comes  as  easily  to  him  as  the  digestion  of  the  daily  meal  which  is  provided 
for  his  bodily  support.  Mathematical  problems  are  solved  with  incredible 
quickness,  and  geometrical  principles  are  mastered  in  such  a  surprising  man- 
ner that  the  knowledge  seems  almost  intuitive.* 

Another  child  of  the  same  parents,  who  is  equally  anxious  and  persever- 
ing, may  not  have  the  same  aptitude;  he  may  have  a  feeble  mind,  and  no 
amount  of  culture  and  drudgery  can  ever  place  him  in  the  front  rank  oi 
scholars,  or  enable  him  to  acquire  more  than  commonplace  facts.  Books 
are  not  the  delight  of  his  eyes ;  the  bent  of  his  inclination  is  not  in  this  di- 
rection. He  sees  nothing  to  grasp  at  and  acquire.  His  restless  struggles  to 
overcome  this  inherent  deficiency  of  mental  endowment  impair  the  structure 
of  a  brain  already  weak,  and  too  often  end  in  miserable  failure  and  disap- 
pointment. We  may  awaken  the  child's  interest  and  understanding  in  the 
work  he  is  set  to  accomplish,  and  render  abstruse  points  clear  by  familiar  il- 
lustration ;  but  unless  his  natural  powers  are  considerable,  no  plan  of  instruc- 
tion can  ever  make  him  a  great  scholar. 

The  power  of  memory  depends  greatly  on  sound  physical  health;  but  also 
on  original  difference  of  constitution,  which  ought  to  be  taken  into  account, 
some  children  being  much  more  remarkable  for  the  faculty  of  acquirement 
than  others.  This  does  not  appear  to  be  invariably  connected  with  super- 
iority of  intellectual  endowments,  for  the  facts  thus  readily  acquired  are  not 
seldom  rapidly  forgotten  ;  the  memory  is  local,  so  to  speak,  and  is  not  ac- 
companied by  a  full  perception  of  the  facts,  as  where  the  attention  is  com- 
plete, and  the  mind  grasps  the  whole  subject,  and  conceives  it  fully  from 
every  point  of  view.  If  close  attention  and  pondering  over  a  subject  enable 
a  child  to  master  it  in  a  given  space  of  time,  a  habit  of  quick  appreciation 
may  be  acquired  ;  but  the  result  is  not  usually  so  fixed  or  permanent,  as 
where  information  is  obtained  in  a  more  deliberate  manner,  and  by  slow 
and  careful  preparation.  In  reading  or  studying  a  book  there  are  certain 
passages  which  strike  the  memory,  and  arrest  it  more  deeply  than  others, 
which  take  a  less  abiding  form  in  the  recollection  ;  again,  there  are  other 
portions  which  lull  the  mind  into  a  listless  and  inactive  condition,  from 
which  it  cannot  be  roused  to  engage  the  feelings,  or  awaken  an  interest. 
This  is  of  deep  importance  in  the  training  of  children  ;  for  that  study  which 
comes  easy  and  pleasant  to  them  is  the  least  exhausting  and  wearisome.  A 
child  will  become  tired  over  an  uninteresting  book,  whilst  one  which  amuses 
and  pleases  him  is  easily  understood,  and  the  facts  remembered.  One 
thought  suggests  another  of  kindred  natnre,  and  the  attention  being  aroused 
by  a  pleasurable  excitement,  there  is  much  less  effort  required  to  master  the 
subject.  Some  persons  are  gifted  with  reflecting  minds,  and  they  have  the 
habit  of  intense  attention  and  correct  association.  They  may  be  taciturn  in 
society,  and  be  considered  stupid  and  dull ;  but  they  carry  away  a  knowl- 
edge of  all  they  see  and  hear,  and  can  reproduce  much  of  the  discussion,  if 
it  happens  to  be  worth  remembering.  "  The  mental  power  which,  in  some 
cases,  is  acquired  by  constant  and  intense  exercise,  is  indeed  astonishing. 

*  A  case  is  mentioned  by  Dr.  Carpenter  of  extraordinary  mathematical  ability  in  a  boy,  the 
son  of  an  American  peasant,  who  had  received  very  little  instruction  in  either  reading  or 
arithmetic,  and  yet  he  surprised  every  one  by  solving  the  most  difficult  arithmetical  questions 
that  were  proposed  to  him,  with  ease  and  accuracy,  at  the  age  of  six  years.  The  immortal 
author  of  the  "  Messiah,"  at  nine  years  of  age,  composed  the  church  service  for  voices  and 
instruments,  and  at  fourteen  far  excelled  many  of  the  most  eminent  musicians  of  his  time. 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE,  121 

Bloomfield,  the  poet,  relates  of  himself  that  nearly  one-half  of  his  poem, 
*  The  Farmer's  Boy,'  was  composed,  revised,  and  corrected,  without  writing 
a  word  of  it,  whilst  he  was  at  work  with  other  shoemakers  in  a  garret."* 
This  was  acquired  by  the  power  of  keeping  the  subject,  which  was  not  a 
Avide  one,  continually  before  his  mind.  When  any  subject  of  inquiry  is  ex- 
tensive and  complex,  it  requires  logical  proof  to  enunciate  the  facts,  and  in- 
volves protracted  and  laborious  study.  If  the  subject  also  demands  great 
exactness  and  precision,  the  intellect  is  much  more  taxed  by  this  nicety  of 
detail  than  by  a  more  simple  generalization. 

Intellectual  strain  and  even  hours  of  labor  are  to  be  carefully  measured 
out  according  to  the  capacity  of  a  child.  So  profound  is  my  conviction  of 
the  danger  incident  on  indiscriminate  taxation  of  the  mental  powers,  and 
that  even  children  with  high  intellectual  endowments  have  had  their  general 
health  damaged  by  this  forcing  process,  that,  notwithstanding  that  they  have 
in  after  life  greatly  distinguished  themselves  in  scholastic  attainments,  I  am 
convinced  that  a  premature  decay  of  the  mental  powers  has  been  invited, 
and  decrepitude  established  years  before  such  a  calamity  would  have  befallen 
them  in  the  ordinary  course  of  nature. f  What  greater  error  could  possibly 
be  conceived  than  to  enforce  close  attention  and  drudgery  over  lessons  when 
the  brain  feels  a  sense  of  weariness,  and  the  bodily  strength  is  weak  ?  The 
application  is  imperfect,  and  attention  cannot  be  given  for  any  length  of 
time,  because  the  vigor  of  the  brain  is  failing,  and  the  intellectual  functions 
are  being  spoiled. 

It  is  considered  certain  by  some  pathologists  that  the  brain  of  childhood 
may  become  hypertrophied,  but  from  what  causes  we  are  not  in  a  position  to 
speak  with  any  degree  of  certainty ;  beyond  this,  that  it  has  generally  been 
observed  in  those  cases  of  bright  children,  who  have  given  evidence  of 
intellectual  precocity ;  and  this  being  so,  it  is  obvious  that  the  undue 
employment  of  the  brain  (especially  if  the  general  health  is  in  any  way 
defective)  may  lead  to  inflammation  of  the  membranes,  or  at  least  to  severe 
congestion,  or  serous  effusion  into  the  ventricles. |  The  anatomical  changes 
after  death  are  extreme  elasticity  and  compressibility,  so  that  the  brain  is  too 
large  for  the  cavity  which  contains  it;  the  upper  portion  of  the  skull  rises 
immediately,  and  the  dura  mater  bulges  out  at  the  sides  from  the  expansion 
beneath,  as  soon  as  the  bone  is  separated  from  the  rest  of  the  cranium.  The 
brain  is  said  to  be  hard  and  pallid,  owing  to  pressure  having  obliterated  the 
bloodvessels.  On  making  a  horizontal  section,  the  gray  matter  is  not  seen 
altered,  and  the  naked-eye  view  displays  an  increase  in  the  amount  of  white 
matter ;  this,  according  to  Rokitansky,  is  owing,  not  to  an  augmentation  in 
the  number  of  nerve  tubes,  or  their  dimensions,  but  to  the  excessive  develop- 

*  On  the  Intellectual  Powers,  by  J.  Abercrombie,  M.  D.,  1871,  19th  edition,  p.  99. 

■j- "  The  forcing  system  has  been  by  many  given  up ;  and  precocity  is  discouraged. 
People  are  beginning  to  see  that  the  first  requisite  for  success  in  life  is  to  be  a  good  animal. 
The  best  brain  is  found  of  little  service  if  there  be  not  enough  vital  energy  to  work  it ;  and 
hence  to  obtain  the  one  by  sacrificing  the  source  of  the  other  is  now  considered  a  folly — a 
folly  which  the  eventual  failure  of  juvenile  prodigies  constantly  illustrates." — Education, 
Intellectual,  Moral,  and  Physical,  by  Herbert  Spencer,  p.  60. 

\  "  There  can  be  no  doubt  that  many  a  child  has  been  sacrificed  in  early  life  to  the  pride 
of  parents,  who,  delighted  with  the  intellectual  activity  of  their  children,  have  striven  to 
make  them  prodigies  of  learning.  But  in  these  cases  of  early  and  undue  employment  of 
the  brain,  inflammation  of  the  hemispherical  ganglion,  or  of  the  lining  membrane  of  the 
ventricles  with  serous  effusion,  has  usually  been  the  cause  of  either  a  fatal  issue  or  of 
subsequent  mental  imbecility." — Solly,  On  the  Brain,  2d  edition,  1847,  p.  662. 


1 22  HEADACHES. 

ment  of  the  intervening  and  nucleated  substance  or  neuroglia."*  Wilks  and 
Moxon,  after  stating  that  they  have  no  special  experience  of  this  condition, 
say  that  in  the  cases  that  have  lately  occurred,  the  hypertrophy  was  un- 
accompanied by  effusion  into  the  ventricles,  which  were  small,  and  that  the 
actual  growth  of  the  cerebral  structure  "  was  found  to  be  due  to  increase  of 
the  neurilemma,  or  cement  between  the  fibres. "f  In  adult  life,  as  we  have 
previously  seen,|  when  the  ossification  of  the  cranial  bones  is  complete,  the 
cerebral  contents  are  not  liable  to  the  same  degree  of  variation  as  in  children, 
where  the  brain  often  attains  considerable  size  and  weight.  From  the 
evidence  which  has  been  obtained  by  scientific  research,  it  seems  conclusively 
established  that  this  disease  is  nwst  likely  to  attack  delicate  and  active- 
minded  children,  just  as  atrophy  of  the  brain  is  sometimes  witnessed  in  young 
subjects,  when  they  have  been  struck  down  by  chronic  and  exhausting 
illness.  It  would  appear,  then,  that  this  and  some  other  morbid  conditions 
of  the  brain  may  attack  children  of  fragile  frame  and  intellectual  energy — 
those  in  whom  the  senses  are  acute,  and  the  imagination  lively ;  whose 
constitutional  debility  is  apparent  in  the  smallness  of  the  chest,  and  the  large 
size  of  the  joints.;  and  the  waste  of  whose  nervous  tissue,  from  over-anxiety 
or  mental  excitement,  is  out  of  all  proportion  to  the  means  of  restoring  it. 

I  think  our  school  boards  have  something  to  answer  for  in  the  measure 
they  deal  out  to  those  parents  who  omit  sending  their  children  regularly  to 
school  when  they  are  not  in  a  fitting  state  to  exert  themselves  in  the  prose- 
cution of  their  studies.  There  may  be  much  to  be  said  in  extenuation  of 
these  severe  measures  from  the  ready  excuses  which  the  poor  offer  for  keep- 
ing their  children  at  home ;  but  they  have  reason  sometimes  on  their  side, 
and  it  is  only  requisite  to  take  a  glance  at  many  of  the  cases  brought  before 
us,  to  see  how  opposed  it  is  to  common-sense  and  reason  to  expect  that  such 
children  should  be  supposed  capable  of  grasping  the  most  simple  facts  with 
health  so  shaken.  I  am  frequently  asked  by  sensible  mothers  who  bring 
their  children  for  hospital  advice,  and  fully  realize  the  importance  of  in- 
struction, to  sign  a  certificate  recommending  absence  from  school  which 
they  may  present  to  the  board.  I  find  that  sleepless  nights,  irritability  of 
manner,  drowsiness  in  the  daytime,  headache,  and  loss  of  appetite  are  the 
usual  train  of  symptoms,  and  they  are  just  what  we  might  anticipate  when 
children  are  imperfectly  fed  and  clothed.  In  nine  cases  out  of  ten,  the 
children  are  anemic,  the  blood  is  poor  and  impoverished,  and  there  is  a 
taint  of  consumption  or  scrofula  in  some  of  its  forms.  Some  parents,  in 
seeking  advice  for  a  child,  tell  me  that  their  children  are  so  anxious  and  in- 
terested in  their  school-work,  that  it  is  painful  to  keep  them  at  home,  but 
the  effects  of  allowing  them  to  go  to  school  are  debility,  headache,  languor, 
depression,  and  loss  of  appetite,  till  they  finally  break  down  altogether, || 
and  this  applies  in  a  far  greater  ratio   to  girls  than   to  boys.     "Beyond 

*  Jones  and  Sieveking's  Pathological  Anatomy,  by  Payne,  2d  edition,  Philadelphia, 
Blakiston,  1875,  p.  272. 

•j- Pathological  Anatomy,  2d  edition,  Philadelphia,  Blakiston,  1875,  P-  ^i^- 
J  See  Chapter  I.,  on  the  Headache  of  Cerebral  Anaemia. 

II  The  returns  of  the  registrar-general  in  England  for  the  year  1874  show  that  30,995 
deaths,  chiefly  among  children,  were  due  to  atrophy  and  debility.  It  was  the  third  on  the 
list  of  deaths  from  filteen  causes,  and  exceeded  the  deaths  from  old  age  by  upwards  of  2000, 
which  comes  next  on  the  list.  Nervous  diseases  are  also  fearfully  on  the  increase,  and  are 
fifth  in  order.  Convulsions,  nearly  all  among  children,  realize  the  high  figure  of  27,139, 
and  is  fourth  on  the  list.  It  exceeded  the  deaths  from  epidemic  and  zymotic  diseases,  as 
scarlet  fever,  measles,  whooping-cough,  and  diarrhoea,  which  strike  down  such  a  large  pro- 
portion of  our  juvenile  population. 


HEADACHES    OF    CHILDHOOD   AND    EARLY    LIFE.  1 23 

doubt,  the  girls,  from  the  fact  that  they  are  girls,  are  more  liable  to  suffer 
than  boys."*  Now  this  in  many  cases  is  caused  by  the  physical  health  be- 
ing so  delicate  that  the  mind  will  not  bear  the  strain.  There  is  no  reserve 
force  to  draw  upon.  How  different  might  this  have  been,  supposing  the  gen- 
eral health  had  received  a  full  share  of  attention,  and  the  culture  of  the  mind 
•  had  been  neglected  till  a  later  period. 

The  aptitude  and  great  desire  for  learning  in  young  children  physically 
weak  and  delicate  is  oftentimes  disastrous.  When  the  health  is  robust,  the 
brain  tolerates  sustained  attention  with  impunity,  particularly  if  the  exercise 
goes  on  unconsciously  (as  in  the  pursuit  of  pleasure),  for  then  the  brain 
escapes  the  fatigue  which  is  the  certain  accompaniment  of  effort.  The  men- 
tal development  of  an  individual  is  inseparably  united  with  the  growth  of 
the  physical  frame,  and  the  two  should  be  looked  at  side  by  side  in  all  their 
relationship.  It  is  an  essential  property  of  the  brain  to  feel  every  debilitat- 
ing power  in  the  smallest  degree,  and  to  call  into  active  operation  the  excit- 
ability of  the  whole  vital  system.  Impressions  made  upon  the  brain  by 
over-exertion,  when  the  body  as  a  whole  is  in  a  state  of  debility  or  exhaus- 
tion, invite  a  degree  of  excitement  or  stimulation,  which  proportionately 
distresses  and  weakens  it.  In  consequence  of  the  presence  of  irritation  in 
distant  and  overtaxed  organs,  the  brain  is  affected,  and  its  functions  are 
suspended  or  excited  according  to  the  amount  of  mischief  which  determines 
the  irritability.  "Continued  activity  of  a  nerve  diminishes  its  irritability 
in  proportion  to  the  time,  and  may  destroy  it  altogether  (exhaustion).  In 
the  former  case  rest  restores  the  nerve  to  its  original  condition.  The  alter- 
ations which  take  place  in  nerves  during  exhaustion  have  not  yet  been  made 
out"  (Hermann).  The  separate  functions  of  life  cannot  long  be  main- 
tained in  health,  under  any  degree  of  excitement,  without  exhaustion  being 
sooner  or  later  felt  in  the  entire  organism.  Every  disturbance  from  the 
most  accidental  cause  is  quickly  responded  to,  and  in  consequence  of  the 
influence  of  sympathy  the  affections  of  each  are  felt,  till  disease  is  compli- 
cated or  incurable,  through  the  bond  of  connection  between  the  vascular 
and  the  nervous  systems. 

Parents  may  take  comfort  from  the  fact  that  a  popular  tradition  is  held  as 
sound  by  many  people,  that  the  boy  who  may  appear  somewhat  heavy  and 
backward  at  first,  may  turn  out  a  distinguished  man  at  last.     This  tradition 

*  School  Hygiene,  by  Dr.  Frederick  Winsor,  Winchester,  Massachusetts.  Quoted  from 
The  Building  of  a  Brain,  p.  72. 

The  size  of  the  brain  may  have  something  to  do  with  this.  "  The  average  weight  of  the 
human  adult  male  brain  is  about  3  lbs.  It  increases  from  one  year  old  up  to  twenty.  Be- 
tween twenty  and  thirty  there  is  a  slight  decrease  on  the  average ;  afterwards  it  increases 
and  arrives  at  its  maximum  between  forty  and  fifty ;  after  fifty  to  old  age  the  brain  gradually 
decreases  in  weight.  Tiedemann,  in  his  paper  on  the  brain  of  the  negro,  states  that  the 
brain  of  the  adult  male  varies  between  3  lbs,  2  oz.  and  4  lbs.  6  oz.  The  brain  of  men  who 
have  distinguished  themselves  by  their  talent  is  often  large.  The  brain  of  Cuvier  weighed 
4  lbs.  II  oz.  4  dr.  30  grains,  troy  weight.  The  brain  of  an  idiot,  fifty  years  of  age,  weighed 
but  I  lb.  II  oz.  4  dr.  The  female  bi-ain  usually  is  lighter  than  the  male.  It  varies  between 
2  lbs.  6  oz.  and  3  lbs.  1 1  oz.  Tiedemann  never  met  with  a  female  brain  that  weighed  4 
lbs.  The  female  brain  weighs  on  an  average  from  4  to  6  oz.  less  than  that  of  the  male,  and 
this  difference  is  already  perceptible  in  the  new-born  child." — Solly,  O71  the  B7-ain,  1847, 
p.  162. 

"  The  average  of  both  sexes  differs,  however,  in  the  various  races  of  mankind.  Dr. 
Davis  (Proceedings  of  the  Royal  Society,  January  23d,  1868,)  found  the  mean  of  the  Euro- 
pean series  to  be  46.87  oz.;  of  the  Asiatic  series,  44.62  oz. ;  of  the  American  series  44.73  oz.; 
of  the  African  series,  44.3  oz.;  and  of  the  Australian  series,  41.38  oz.  Dr.  Thurnam  (Jour- 
nal of  Medical  Science,  April,  1866)  gives  49  oz.  as  the  average  weight  of  the  European 
brain,  whilst  in  distinguished  men  it  amounts  to  54.6  oz."— Quoted  from  Carpenter's  Human 
Physiology,  by  Power,  8th  edition,  1876,  p.  786. 


1 24  HEADACHES. 

is  not  a  mere  fancy  or  superstition,  but  is  founded  on  the  every-day  exper- 
ience of  people  who  have  seen  the  facts  for  themselves,  and  who  are  not 
simply  bent  on  propounding  a  theory.  Parents  may  equally  take  warning 
from  the  fact  that  mental  strain  encouraged  to  excess  in  delicate  children  is 
almost  certain  to  entail  disastrous  consequences.  If  such  children  are  ab- 
surdly pressed  by  the  vanity  of  parents,  or  the  mistaken  views  of  teachers, 
the  extreme  point  of  tension  is  not  generally  discovered  till  it  is  exceeded, 
and  the  result  of  early  forcing  is  too  often  to  produce  a  state  of  brain  which 
at  its  best  never  afterwards  rises  above  the  level  of  mediocrity. 

According  to  Professor  Laycock,  precocious  children  are  usually  of  the 
strumous  type,  which  he  terms  an  approach  to  a  ''lower  ethnic  form,"  and 
which  is  more  or  less  incompatible  with  high  intellectual  development ; 
hence  the  common  phrase,  that  "  some  children  are  too  clever  to  live." 

The  question  will  be  asked  by  parents,  and  those  engaged  in  education : 
When  may  we  put  pressure  on  with  safety?  The  age  of  the  child  is  not  a 
criterion,  and  I  can  conceive  of  no  greater  error  than  to  attempt  the  adop- 
tion of  any  general  rule  which  shall  be  applicable  to  all  cases ;  for  children 
differ  widely  from  each  other  in  a  hundred  ways,  and  what  will  prove  a 
healthy  stimulus  to  some  will  exhaust  and  overthrow  others.  If  a  child  has 
had  his  intellect  carefully  and  slowly  imfolded,  he  will  be  in  a  very  different 
position  at  six  or  seven  years  of  age  to  one  whose  culture  has  been  neglected 
up  to  that  time;  the  memory  may  be  exercised  with  safety,  and  the  gift  of 
imitation,  so  strong  in  childhood,  made  use  of  from  a  very  tender  age.  The 
mind,  like  the  body,  is  amenable  to  rational  management ;  and  when  this  is 
gradual,  and  not  premature  or  forced,  the  facility  of  acquirement  will  be  all 
the  more  ready.  The  process  of  additional  pressure  may  be  conducted  with 
a  full  appreciation  of  what  the  child  can  accomplish  with  pleasure,  and  must 
not  cause  weariness.  This  appears  to  be  about  the  only  rule  we  are  justified 
in  suggesting,  and  we  must  discriminate  between  the  strong  vigorous  child 
who  can  bear  the  pressure,  and  the  weak  excitable  child  who  is  probably  of 
the  two  the  more  willing  and  anxious  to  learn.  Looking  at  the  physical 
health  of  a  child  as  a  means  of  judging  of  its  mental  strength,  I  think  the 
commencement  of  the  second  dentition  is  the  earliest  period  when  instruc- 
tion requiring  brainwork  can  be  safely  pushed.  Even  then  the  knowledge 
should  be  of  a  kind  which  accords  with  the  evolution  of  the  different  facul- 
tses,  or  the  mind  will  become  disgusted  with  the  difficulties  placed  before  it, 
and  not  having  mastered  simple  subjects,  it  will  be  unfit  to  receive  more 
complex  ones;  hence  precise  methods  of  instruction  and  exact  definitions, 
if  attempted  too  soon,  will  be  fraught  with  evil,  and  the  child  will  languish 
under  the  accumulation  of  facts  with  which  its  mind  is  weighted. 

Let  us,  then,  consider  the  question  of  dentition  in  its  relation  to  the 
physical  and  mental  growth  of  childhood.  The  eruption  of  the  first  set  of 
teeth  is  determined  by  the  state  of  the  nervous  system,  the  quality  of  the 
food  that  is  supplied,  and  the  surrounding  conditions  of  pure  air  and  water; 
it  is  much  more  delayed  in  some  children  than  in  others,  and  notably  in 
those  who  are  weakly  and  delicate,  or  whose  development  is  retarded  by  a 
rickety  constitution.  When  it  does  commence  the  nervous  system  is  dis- 
turbed, and  convulsive  affections  not  unfrequently  ensue.  Now,  if  convul- 
sions happen  from  time  to  time,  the  nerve-centres  are  rendered  still  more 
excitable,  and  the  brain  is  weakened,  which  weakness  may  show  itself  at  the 
time  of  the  second  dentition. 

The  period  of  the  second  dentition,  which  begins  about  the  seventh  or 
eighth  year,  must  be  reckoned,  from  this  point  of  view,  the  most  important 
period  of  childhood — the  period  when  educational  training  should  be  cau- 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE.  1 25 

tiously  proceeded  with,  because  then  the  physical  growth  is  very  active,  and 
the  animal  functions  are  proceeding  with  extraordinary  rapidity,  and  a  large 
amount  of  rest  and  sleep  are  required  for  the  building  up  of  the  tissues.  This 
period  in  some  children  is  of  much  longer  duration  than  in  others,  lasting  in 
weakly,  rickety  subjects  till  thirteen  or  fourteen.  The  rule  of  the  Factory 
Laws  does  not  allow  a  child  to  work  before  the  age  of  nine,  and  at  thirteen 
only  nine  hours  a  day,  the  gradual  development  of  the  teeth  being  taken  as 
the  best  standard  of  physical  capability,  and  a  more  reliable  test  of  age  than 
height,  because  it  is  very  well  known  that  the  tallest  children  are  generally 
the  most  weak  and  fragile  {Carpenter'' s  Hinna?i  Physiology,  page  1105). 
During  childhood  the  digestive  organs  are  very  active,  and  derangements 
which  are  brought  about  by  perverted  nutrition  are  especially  common.  If 
disorders  of  the  digestive  organs  become  chronic,  any  trifling  cold  may  pro- 
voke an  inflammatory  attack,  and  hence  tuberculous  diseases  are  frequent,  a 
latent  strumous  diathesis  being  called  into  activity.  Any  immoderate  intel- 
lectual training  at  a  time  when  the  digestive  organs  are  enfeebled,  and  the 
appetite  poor,  may  so  impoverish  the  quality  of  the  blood  as  to  increase  the 
irritability  of  the  nervous  centres.  Two  instances  of  this  kind  have  come 
under  my  observation,  where  delicacy  of  the  general  health,  with  ordinary 
mental  exertion,  was  followed  by  tubercular  disease  of  the  brain  in  young, 
bright,  clever  lads,  aged  respectively  eight  and  eleven  years.  In  neither 
instance  could  any  blame  be  attached  to  the  mental  training  ;  but  the  physi- 
cal health  in  both  cases  had  not  reached  that  standard  of  strength,  or  perhaps 
could  not  reach  it,  which  admitted  of  any  tension  or  concentrated  employ- 
ment of  the  faculties. 

Some  children  are  naturally  quick  and  active-minded,  and  they  will  make 
rapid  progress  in  their  studies,  and  achieve  with  ease  what  is  unattainable  by 
others;  or,  at  least,  if  it  is  accomplished  by  another  child,  it  is  at  great  ex- 
pense, and  at  the  possible  risk  of  a  complete  breakdown.  It  is  undesirable 
to  make  a  great  demand  upon  the  intellectual  powers  till  the  completion  of 
growth,  when  the  demands  upon  the  system  are  distinctly  lessened;  all  the 
functions  of  life  cannot  bear  severe  strain  at  the  same  time,  and  therefore 
advantage  should  be  taken  of  the  intervals  of  growth  when  it  is  compara- 
tively quiescent.  How  frequently  does  it  happen  that  a  long  and  trying  ill- 
ness has  kept  a  boy  from  school,  and  he  has  lost  so  much  time  that  it  seems 
impossible  that  he  can  make  it  up  again ;  yet,  on  recovery,  the  period  of 
inactivity  has  had  a  most  salutary  effect,  and  he  is  not  long  in  coming  up  to 
the  level  of  his  competitors  and  rivals. 

I  have  adopted  the  following  classification  of  headaches: 
(i)  Cerebral    headache,  attributable  to  injury,   or   to  acute  or  chronic 
inflammation. 

(2)  Gastric  headache,  from  intestinal  and  hepatic  derangement,  known 
as  bilious  headache  {sympathetic  headache'). 

(3)  Epileptic  headache  {congestive  headache). 

(4)  Febrile  headache  {active  hyperce7fiia  or  active  congestion). 

(5)  Headache  from  ansemia,  neuralgia,  etc.,  constituting  nervous  head- 
ache. 

(6)  Headache  depending  on  some  intricate  change  in  the  cerebral  mem- 
branes or  tissues  of  the  brain. 

(7)  Organic  headache. 

(i)  Cerebral  headache  seems  to  me  an  appropriate  term  for  a  variety  of 
headache  which  has  supervened  on  a  blow  or  injury  to  the  head.  The 
slight  concussion  so  induced  has  interrupted  the  functions  of  the  brain,  and 
disturbed  the  circulation.     No  notice  is  taken  at  the  time  of  the  accident, 


126  HEADACHES. 

although  there  may  have  been  disturbance  of  sensation,  or  voluntary  motion, 
giddiness,  and  even  nausea  may  have  been  the  evidence  of  disturbance;  but, 
passing  off  quickly,  neither  the  patient  (if  old  enough  to  reflect  on  the  cause) 
nor  the  friends  have  a  notion  that  so  slight  an  injury  could  be  associated 
with  the  oppressive  headache  which  ensues.     The  circumstances  under  which 
the  brain  usually  reveals  its  weakness  are  the  exercise  of  the  intellect,  chronic 
illness,  deficient  food,  and  imperfect  ventilation.     The  brain  cannot  tolerate 
any  ordinary  strain  without  becoming  exhausted,  and  the  intellect  is  so  en- 
feebled that  in   many  cases  all  attempts  at  education  have  to  be  given  up. 
The  headache  is  almost  invariably  frontal,  and  I  would  go  so  far  as  to  hazard 
the  opinion  that  the  anterior  lobes  never  escape.     In  some  cases  the  pain  is 
also  occipital,  but  I  have  seldom  observed  it  exclusively  in  this  situation, 
and  when  it  has  been  severe,  the  pain  in  the  forehead  has  been  less  intense 
and  overpowering.     No  degree  of  pain  in  the  back  of  the  head,  according 
to  my  experience,  produces  such  vital   prostration  and  loss  of  energy,  as  a 
less  degree  of  suffering  will  occasion  in  the  frontal  region.     The  patient  has 
a  dull  and  languid  look ;  there  is  no  animation  in  the  expression ;  the  eyes 
are  sunken  in  the  orbits,  and  move  sluggishly ;  the  lower  eyelids  are  dark, 
and  the  face  is  pallid  and  drawn;  the  skin  is  cool,  and  the. extremities  cold 
or  chilly,  because  there  is  a  disinclination  to  exertion ;  the  pulse  is  soft  and 
slow,  and  the  bowels  disposed  to  constipation.     The  psychological  symptoms 
are  an  alteration  in  ordinary  manner  and  character,  so  much  so  that  the 
friends  tell  us  that  he  is  not  like  the  same  child.     He  takes  no  interest  in 
anything,  and  lies  about  in  one  corner  of  the  room,  as  though  depressed  or 
unhappy;   he  Avill  doze  in  the  daytime  and  sleep  soundly  at  night.   Petulance 
and  irritability  are  not  features  of  this  condition,  the  nerve-centres  not  being 
so  much  involved  Tat  least  primarily)  as  the  vascular  system,  which,  being 
overloaded,  the  want  of  contractility  in  the  vessels  favors  congestion  and 
serous  exudation  into  the  brain-structure  itself.      Cases  with  a  history  of  this 
character  cannot  receive  too  much   attention,  and   the  prognosis   should 
always  be  careful  and  guarded.     Trifling  excitement  may  set  up  inflamma- 
tory action,  or  renew  the  congestion,  which  it  is  so  necessary  to  remove 
before  the  brain  has  sustained  irreparable  injury.     For  this  congestion,  be- 
coming localized,  may  lay  the  foundation  of  a  tumor  or  morbid  growth,  and 
our  attention  in  after  years  is  not  directed  to  the  injury  till  continuous  or 
paroxysmal  pain  in  the  head,  loss  of  power  in  the  limbs,  defective  vision,  or 
obstinate  vomiting,  indicates  the  presence',  of  serious  mischief  in  the  brain. 
If  the  case  goes  on,  the  general  weakness  increases,  and  the  child  is  laid  up, 
giving  every  one  the  idea,  by  his  looks  and  manner,  that  he  is  laboring 
under  disease  of  the  brain.     Any  indiscretion  in  diet  causes  flushing  of  the 
face,  accelerated  pulse,  and  often  vomiting.     Not  unfrequently  the  symptoms 
increase  in  severity,  and  meningitis  ensues;  there  is  rigidity  of  the  arms  and 
legs,  the  head  is  thrown  back  against  the  spine,  the  thumbs  are  hidden  in 
the  palms  of  the  hands  by  the  flexor  tendons,  the  cheeks  are  flushed,  the 
temperature   rises,    and    the   bladder   is    paralyzed.     Now   the   respiration 
becomes  sighing  and  irregular,  the  bowels  act  involuntarily,  the  child  cannot 
be  roused  to  swallow  anything,  and  convulsions  or  coma  usher  in  death. 
After  death,  in  such  cases  as  these,  there  may  be  presented  on  a  post-mortem 
examination  the  evidences  of  extreme  congestion  in  the  veins  ramifying 
over  the  dura  mater,  and  in  the  sinuses  and  base  of  the  brain  ;  the  lateral 
ventricles  may  contain  serous  fluid  in  excess,  and  when  the  brain  is  sliced, 
the  puncta  vasculosa  are  everywhere  turgid  with   blood,  which  oozes  out 
gradually  from   their  open  mouths   after  section.     It   is  important  not  to 
ascribe  too  hastily  to  inflammatory  action  what  in  reality  may  be  due  to 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE.  12/ 

excessive  congestion.  When  the  symptoms  of  meningitis  are  well  marked 
in  young  children,  they  may  generally  be  assigned  to  tubercle.  If  there  i.s 
much  elevation  of  temperature,  and  fever,  we  need  have  no  hesitation  on 
the  subject.  But  a  more  slow  and  insidious  form  of  meningitis  may  arise. 
In  these  cases  the  temperature  is  normal  or  nearly  so,  the  pulse  is  habitually 
slow,  but  rises  rapidly  on  any  excitement  or  after  food  ;  the  limbs  waste  ar.d 
become  powerless,  the  child  is  irritable  and  fretful ;  he  sleeps  badly  at  night, 
and  is  so  restless  that  the  clothes  cannot  be  kept  over  him.  These  are  the 
most  favorable  cases.  The  injury  has  been  so  slight  as  to  provoke  into  ac- 
tion a  slumbering  strumous  diathesis,  or  a  delicacy  of  constitution,  which 
but  for  the  accident  may  never  have  been  developed,  or  certainly  not  till  a 
later  period,  when  the  intellect  has  been  subjected  to  extra  exertion,  or  the 
child  has  been  struck  down  by  an  eruptive  fever  or  exhausting  diarrhoea. 

The  treatment  consists  in  subduing  any  congestive  or  inflammatory  symp- 
toms that  arise  by  careful  diet  and  the  observance  of  strict  hygienic  rules, 
the  avoidance  of  all  excitement,  and  everything  that  tends  to  disturb  the 
equanimity  of  the  mind;  for  children  become  quickly  alive  to  surrounding 
circumstances,  and  mentally  appreciative  of  all  that  goes  on  around  them. 
In  some  cases  that  have  fallen  under  my  notice,  counter-irritation  at  the  back 
of  the  neck  has  answered  well,  especially  if  there  has  been  pain  in  the  occi- 
put and  the  muscles  are  stiff.  If  the  child  is  not  old  enough  to  complain,  he 
will  often  raise  his  hand  teethe  back  of  his  head  to  indicate  the  seat  of  mis- 
chief. I  saw  a  male  child  in  November,  1876,  aged  fourteen  months,  who 
had  cut  most  of  his  teeth  with  comparative  ease,  except  with  one  slight  con- 
vulsion six  months  previously.  About  three  months  before  I  saw  him  he 
struck  his  head ;  and,  although  no  bad  consequences  ensued  till  the  present 
illness,  when  I  saw  him  in  consultation  with  the  ordinary  medical  attendant 
of  the  family,  I  have  no  doubt  of  the  accident  having  laid  the  foundation  of 
the  congestion  and  meningitis,  which  carried  him  off  after  four  days  from 
gradual  unconscioness  passing  into  deep  coma. 

(2)  Gastric  Headache  (Sympathetic  Headache). —  This  is  not  uncom- 
mon in  children,  from  errors  in  diet  and  over-feeding;  but  it  is  less  frequent 
with  them  than  with  adults,  who  are  more  prone  to  irregularity  in  eating 
and  drinking.  It  is  to  be  understood,  however,  that  gastric  disorder  or 
sympathetic  dyspepsia  is  often  met  with  from  irritation  elsewhere;  for  in- 
stance, it  may  be  the  result  of  ascarides  in  the  rectum  or  worms  in  the 
bowels ;  but  we  must  not  forget  that  the  real  cause  of  the  disturbance  may 
be  inflammation  of  the  brain  or  its  membranes  in  children.  Irritability, 
peevishness,  languor,  may  give  rise  to  reflex  irritation,  as  we  have  seen  in 
the  previous  chapter.  Where  the  brain  is  affected  vomiting  is  a  constant 
symptom,  and  in  those  who  die  the  mucous  membrane  and  its  larger  ex- 
tremity is  found  digested,  or  dissolved  by  the  gastric  juice — a  proof  that 
the  irritation  of  the  brain  excites,  at  least  in  many  cases,  untimely  secretion 
of  gastric  acid  (Budd,  07i  the  Stomach,  p.  193)-  Andral  has  pointed  out 
that  these  patients  often  throw  up  a  large  quantity  of  greenish  bile  with 
painful  efforts.  In  addition  to  pain  and  tenderness  at  the  epigastriumi,  there 
is  in  most  cases  severe  pain  in  the  head.  This  disease  also  occurs  in  chil- 
dren from  tubercular  disease  of  the  lungs,  and  it  is  not  uncommon  during 
the  first  dentition,  at  the  time  of  weaning,  if  they  have  been  reduced  by  the 
eruptive  fevers,  or  by  improper  food  and  impure  air.  They  are  thirsty  and 
fretful,  the  vomited  matters  are  sour,  and  the  bowels  loose  and  the  motions 
greenish.  Exhaustion  may  set  in  with  coldness  of  the  surface,  and  death. 
In  infants  the  gums  should  be  lanced,  and  a  diet  of  milk  given,  or  a  wet- 
nurse  procured,  as  the  case  may  be ;  and  bismuth,  magnesia,  logwood,  and 


128  HEADACHES, 

krameria  given,  with  aromatic  spirits  of  ammonia,  hydrocyanic  acid, 
morphia,  etc.  It  is  most  common  in  children  who  are  reduced  by  previous 
ilhiess,  and  who  are  fragile  and  excitable.  In  many  cases  of  this  sympathetic 
disorder,  there  is  no  remedy  that  will  give  relief  till  the  irritatioa  of  the  blood 
and  brain  subsides.  The  stomach  secretes  unhealthy  mucus,  which  causes 
fermentation  in  the  starchy  principles  of  the  food,  and  lactic  acid  is  formed, 
which  disturbs  both  stomach  and  bowels.  The  gases  generated  by  the 
stomach  where  flatulence  exists  are  carbonic  acid,  nitrogen,  and  sulphuretted 
hydrogen ;  and  there  is  nearly  always  headache  in  these  cases. 

These  headaches  in  children  are  constantly  due  to  the  choice  of  food  and 
drink,  and  to  preserve  health  and  strength  it  is  obvious  that  the  supply 
should  be  in  suitable  proportions,  according  to  age,  sex,  and  occupation. 
"  Thus  we  may  estimate  that  a  child  of  eight  or  nine  years  of  age,  as  con- 
trasted with  a  full-grown  adult,  actually  gives  off,  relatively  to  the  weight  of 
its  body,  one  and  a  half  times  as  much  carbonic  acid ;  and  the  same  rule 
probably  applies  to  its  urea."*  It  stores  up  in  its  body  a  larger  portion  of 
the  constitutents  of  its  food,  and  a  smaller  quantity  of  effete  matter  is 
dismissed  from  its  body  by  the  various  emunctory  functions ;  and  it  con- 
sequently becomes  apparent  why  the  food  in  the  case  of  children  should  be 
purer  and  easier  of  assimilation  than  in  adults,  whose  powers  of  assimilation 
are  so  much  stronger,  and  are  capable  of  chemically  converting  into  the 
textures  of  the  body  ingredients  which  the  feeble  power  of  digestion  in 
young  children  is  incapable  of  transforming.  "The  morphological  and 
chemical  changes,  for  example,  which  transform  the  cartilaginous  femur  of 
the  infant  into  the  bone  bearing  the  same  name  in  the  adult,  imply  such 
large  and  incessant  demands  on  the  part  of  its  organism  for  lime,  magnesia, 
and  phosphoric  acid,  as  may  well  suggest  the  possible  magnitude  of  the 
contrast  in  the  proportions  of  these  inorganic  substances  required  to  be 
present  in  its  food.  Nor  does  the  circumstance  that  such  a  contrast  is 
probably  only  quantitative,  much  affect  the  deducible  result. "f 

(3)  Epileptic  Headache  (Congestive). — The  headache  that  accompanies 
epilepsy  is  deserving  of  some  consideration  ;  and  to  those  who  are  the  un- 
fortunate subjects  of  it,  it  will  be  found  a  frequent  and  distressing  symptom. 
Drowsiness,  lethargy,  heavy  sleep,  disturbed  dreams,  and  want  of  animation, 
are  premonitory  symptoms  of  the  attack,  so  frequent  as  not  to  be  disregarded. 
But  headache  is  more  commonly  a  consequence  of  the  attack,  and  as  such  it 
chiefly  concerns  us  at  present.  Of  fifty-six  cases  recorded  by  Dr.  Sieveking 
in  which  headache  occurred,  it  was  constant  or  frequent  in  twenty-eight 
cases;  it  occurred  before  the  fits  in  four  cases  only,  after  the  fits  only  in 
twenty-two  cases,  and  it  occurred  both  immediately  before  and  after  the 
seizure  in  three  cases. |  These  headaches  are  of  a  congestive  character,  and 
they  present  a  different  class  of  symptoms  in  some  cases  to  what  they  do  in 
others.  If  the  epileptic  is  of  the  sanguine  temperament,  and  of  full  habit, 
the  headache  is  accompanied  by  heat  of  surface,  throbbing  of  the  temporal 
vessels,  and  fulness  of  the  veins  about  the  scalp;  the  face  is  some- 
times flushed  and  the  eyes  suffused,  the  patient  cannot  bear  the  ap- 
proach of  light,  and  if  he  sleeps  he  wanders  and  is  disturbed  and  restless. 
This  condition,  in  fact,  is  an  acute  form  of  congestion  or  hypersemia  of  the 
vessels,  such  as  we  get  in  the  headache  which  attends  the  early  periods  of 

*On  Food  and  its  Digestion,  by  W.  Brinton,  M.  D.,  1861,  p.  426. 
f  On  Food  and  its  Digestion,  p.  427. 
\  On  Epilepsy,  2d  edition,  p.  59. 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE.  1 29 

some  acute  diseases,  as  pneumonia,  whooping-cough,  and  that  which  I  shall 
next  describe  as  feb7'ile  headache.  In  other  cases,  again,  the  congestive 
headache  is  more  passive.  It  is  better  described  as  passive  hypersemia,  on 
which  we  have  dwelt  in  an  earlier  chapter.  The  effect  of  the  epileptic  par- 
oxysm is  to  disturb  the  equilibrium  of  the  circulation,  and  to  induce  relaxa- 
tion in  the  vessels,  while  a  tardiness  of  the  circulation  springing  from  the 
central  organ  of  life — the  heart — favors  a  blood  stasis  in  the  sinuses  and  ves- 
sels of  the  brain.  That  epilepsy  should  induce  severe  headaches  when  the 
attacks  are  frequent  is  just  what  we  might  reasonably  anticipate,  seeing  that 
the  effect  of  repeated  paroxysms  is  to  damage  the  nervous  substance  of  the 
brain,  to  impair  the  memory,  and  to  lead  in  some  instances  to  idiocy,  or 
even  dementia. 

I  have  met  Avith  most  agonizing  cases  of  headache  in  children  the  subjects 
mitral  regurgitation  or  insufficiency.  In  one  case  which  was  under  my  care 
at  intervals  for  upwards  of  three  years,  the  suffering  was  acute  and  unremit- 
ting ;  the  poor  girl  presented  the  appearance  of  a  much  older  person,  the 
cheeks  had  a  dusky  crimson  flush  on  them,  and  the  brain  was  habitually 
overloaded  with  venous  blood.  The  superficial  veins  of  the  neck  and  scalp 
were  distended,  and  the  temporal  arteries  throbbed  violently,  for  the  oc- 
casional epistaxis,  which  had  brought  relief  from  time  to  time,  had  long 
since  ceased  to  recur.  Active  purgation,  by  means  of  a  grain  of  calomel  at 
night,  and  a  febrifuge  and  saline  aperient,  failed  on  some  occasions  to  give 
relief,  and  I  was  compelled  to  leech  the  temples,  which  for  a  time  lessened 
the  tumultuous  action  of  the  heart,  and  alleviated  the  headache. 

Treatnwnt. — This  must  be  regulated  according  to  the  strength  and  consti- 
tution of  the  patient.  If  the  child  is  of  a  nervous  disposition,  the  surface 
pale,  and  the  circulation  languid,  small  doses  of  strychnia  with  a  mild  prep- 
aration of  iron  will  be  useful,  by  increasing  the  tone  of  the  system  generally, 
and  a  stimulating  liniment  at  the  back  of  the  neck  will  relieve  the  headache. 
The  extremities  should  be  kept  warm,  and  moderate  exercise  encouraged. 
Sponging  the  body  with  Tidman's  sea  salt  will  be  beneficial ;  it  improves 
the  force  and  character  of  the  capillary  circulation,  and  in  some  degree  re- 
moves the  liability  to  headache  and  cerebral  congestion.  In  the  case  of 
stronger  children  a  calomel  purge,  followed  by  a  saline  aperient  in  the  early 
morning,  will  be  necessary,  if  the  bowels  are  disordered,  or  worms  are  sus- 
pected. Sulphate  of  zinc,  in  a  bitter  infusion,  is  a  remedy  worth  trying  in 
some  cases  :  it  improves  the  appetite,  and  imparts  a  degree  of  vigor  to  the 
digestive  functions  which  relieves  the  oppressive  headache.  If,  however, 
the  headache  is  continuous  and  acute,  bromide  of  potassium  alone,  or  com; 
bined  with  bark,  ammonia,  or  valerian,  will  be  advisable  till  its  severity  is 
mitigated  ;  and  when  the  pulse  is  quick  and  unsteady,  or  anaemia  is  present, 
digitalis  with  iron  may  have  a  beneficial  effect,  by  reducing  the  venous  ful- 
ness and  promoting  the  force  of  the  arterial  current. 

(4)  Febrile  Headache. — I  speak  of  this  variety  of  headache  because  the 
brain  is  active  and  susceptible  in  young  persons,  and  the  circulation  being 
additionally  excited  by  the  fever  process,  the  vessels  convey  a  larger  quan- 
tity of  blood  to  the  brain  than  they  do  in  health.  If  the  subjects  of  fever 
are  robust  and  strong,  the  hyperemia  of  the  vessels  is  all  the  greater.  In 
typhus  fever  the  headache  is  frequently  most  intense — dull  and  heavy  across 
the  forehead  and  in  both  temporal  regions.  Sometimes  the  pain  extends 
over  the  whole  head,  and  is  not  confined  to  the  vertex  or  occiput;  nor  is  it 
so  throbbing,  darting,  or  bursting  as  in  relapsing  fever  or  the  headache  of 
some  other  febrile  disorders.  In  the  typhoid  fever  of  children  there  is  usu- 
ally dull  frontal  headache,  and   the  mental  faculties  are  disturbed  ;  some- 


1 30     '  HEADACHES. 

times  delirium  or  convulsions  ensue,  but  more  frequently  there  is  a  moder- 
ate degree  of  headache  during  convalescence,  if  the  patients  have  exerted 
theinselves  too  much,  or  have  been  awake  too  long,  or  without  food.  In  all 
acute  diseases  we  should  be  on  the  lookout  for  headache,  as  it  is  of  common 
occurrence  in  pneumonia,  bronchitis,  whooping-cough,  and  the  various 
exanthemata.  I  have  observed  it  extremely  severe  in  scarlet  fever  and 
measles,  particularly  before  the  eruptive  stage  is  fully  developed. 

In  the  treatment  of  headaches  complicating  these  febrile  affections,  a  few 
leeches  to  the  head,  cold  affusion,  or  the  ice-cap,  will  sometimes  be  advis- 
able to  control  the  vascular  excitement  within  the  head,  and  reduce  the 
activity  of  the  cerebral  circulation;  whilst  the  specific  diseases  on  which 
they  depend  must  receive  proper  attention. 

(5)  The  headache  of  ancemia,  neuralgia,  etc.,  may  be  classified  as  nervous 
headache,  and  the  description  given  in  the  first  and.  seventh  chapters  will  be 
found  to  include  all  that  is  important  under  this  variety  in  children. 
Neuralgic  headache  ■as.Mally  aS^acis  those  of  a  timid  and  delicate  constitution, 
and  if  they  have  been  reduced  by  acute  or  chronic  disease,  it  is  readily 
excited  in  them.  I  have  met  with  it  in  boys  and  girls  whose  intellects  have 
been  overtaxed  during  study  and  confinement  to  long  and  wearisome  lessons. 
It  is  also  induced  by  indoor  confinement  and  bad  air,  though  it  is  not  so 
common  from  these  causes  as  the  congestive  form  of  headache,  in  which  the 
vessels  are  over-distended.  Dr.  West  says:  "It  does  not  by  any  means 
depend  on  overstudy,  though  I  do  not  ever  remember  meeting  with  it  in 
children  who  have  not  yet  gone  into  the  schoolroom  ;  and  I  have  frequently 
found  it  dependent  on  too  continuous  application,  though  the  number  of 
hours  devoted  to  study  in  the  course  of  the  day  may  not  have  been  by  any 
means  excessive."*-  From  my  own  experience  I  have  certainly  observed  it 
quite  as  often  among  children  whose  intellect  has  not  been  overtried,  or  even 
exerted  at  all ;  and  I  am  inclined  to  the  view  that  any  depressing  causes,  or 
unhealthy  surroundings,  are  capable  of  exciting  it  into  action.  I  have  seen 
a  bad  attack  in  a  boy,  aged  fifteen,  whose  nervous  system  was  reduced  by  a 
long,  and  trying  local  disorder.  Neuralgia  of  the  ophthalmic  and  temporal 
branches  of  the  fifth  nerve,  succeeding  lymphatic  obstruction  and  painful 
muscular  spasms  in  one  lower  limb,  were  experienced  on  several  occasions. 
He  was  often  kept  awake  at  night,  and  had  become  so  nervous,  that  sleep 
could  not  be  obtained  till  he  took  some  brandy  and  water,  and  the  attack 
was  only  removed  by  a  generous  diet,  and  full  doses  of  quinine  three  times 
a  day.  Whenever  at  his  best  time  he  took  a  longer  walk  than  he  was  able 
to  accomplish  with  comfort,  he  was  liable  to  headache.  I  have  known  fear- 
ful neuralgia  to  come  on  in  delicate  girls  of  thirteen  or  fourteen,  who  are 
approaching  the  catamenial  period,  but  in  whom  it  has  not  appeared,  or  is 
delayed,  particularly  if  the  intellect  has  been  strained,  especially  where  the 
temperament  is  over-anxious.  These  patients  are  more  frequently  seen  in 
the  out-patient  department  of  our  hospitals  than  in  private  practice,  for  poor 
living  is  a  great  determining  cause.  They  are  pale  and  anaemic,  and  some 
of  them  have  been  thrust  into  situations  of  hard  work,  which  they  have  not 
the  strength  to  fill ;  and  if  there  is  cough  and  loss  of  appetite,  a  consumptive 
tendency  can  be  frequently  detected. 

A  case  of  supraorbital  neuralgia  is  recorded  by  Mr.  Nunn  in  a  young  lady 
about  eleven,   which  yielded  to  lancing  of  the  second  molar  tooth. f     A 

*0n  Some  Disorders  of  the  Nervous  System  in  Childhood  (Lumleian  Lectures,  1871), 
P-   15- 

f  See  a  paper  on  Irrritation  of  the  Dental  Nerve,  in  British  Medical  Journal,  May  5th, 
1877. 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE.  1 3  I 

similar  case  also  came  under  my  own  notice  in  a  girl  of  ten,  who  had  suffered 
very  severe  headache  for  many  weeks.  The  first  molar  tooth  on  the  left  side 
was  extracted,  and  from  that  time  the  patient  began  to  recover.  Headache 
from  dental  caries  is  more  rare  in  children  than  adults. 

In  one  case  that  came  under  my  care  in  October,  1876,  pleurodynia  was 
added  to  the  acute  supraorbital  and  temporal  pain,  and  there  was  a  fearful 
degree  of  apprehension  and  nervousness.  This  assemblage  of  symptoms  was 
mainly  brought  about  by  the  ordinary  causes  which  induce  anaemia.  In  the 
case  of  a  little  girl,  eight  years  of  age,  who  first  came  under  my  care  in 
November,  1876,  with  cardiac  spasm  (angina  pectoris),  there  was  pallor  of 
the  face,  weak  pulse,  and  headache  of  a  neuralgic  character  supervening.  If 
the  second  dentition  is  delayed,  and  the  teeth  are  slow  in  appearing, 
neuralgic  headache,  involving  the  branches  of  the  fifth  nerve  as  they  ramify 
over  the  brow  and  temple,  is  oftentimes  very  acute  in  boys  and  girls.  The 
symptoms  which  denote  neuralgic  headache  are  localized  pain  in  one  temple, 
or  half  of  the  forehead,  coming  on  in  paroxysms;  very  frequently  it  is  situ- 
ated over  the  brow,  or  supraorbital  ridge,  and  the  ball  of  the  eye  is  tender. 
The  pain  seldom  extends  across  the  forehead,  but  remains  limited  to  one 
side  of  the  head,  and  either  passes  superficially  beneath  the  muscles  of  the 
scalp  to  the  occiput,  or  in  stabbing  paroxysms  through  the  eye  itself,  in  the 
same  direction.  Vomiting  is  not  a  frequent  symiptom,  nor  yet  the  disposi- 
tion to  refuse  food  ;  but  when  the  attack  is  severe,  and  one  eye  is  much 
affected,  there  will  be  nausea  and  sickness,  tears  will  course  down  the  cheek, 
and  light  and  sound  will  increase  the  suffering.  Sometimes  this  is  so  violent 
that  the  patient  has  fainted  away,  and  the  timidity  of  the  child's  nature  has 
been  so  nurtured  by  it,  that  it  could  not  sleep  alone,  or  be  left  in  the  room 
at  night  without  a  candle.  Sometimes  the  pain  will  come  on  in  the  morn- 
ing, and  depart  after  a  good  meal,  or  it  will  occur  in  the  evening  when  the 
child  is  exhausted,  and  ought  to  be  in  bed.  The  pulse  is  usually  small, 
excitable,  and  quick,  or  even  intermittent,  and  the  emotions  are  so  sensitive 
that  the  child  will  cry  at  the  expression  of  any  word  that  savors  of  the  least 
harshness.  When  the  pain  is  of  such  continuance  as  to  reduce  the  child's 
health,  the  intestinal  secretions  are  disordered,  and  the  urinary  secretion  is 
excessive,  or  it  abounds  in  lithates.  The  whole  expression  is  one  of  languor 
and  exhaustion,  and  the  child  is  incapable  of  any  mental  exertion.  In  the 
intervals  of  pain  there  may  be  a  full  display  of  cheerfulness,  and  the  stupor 
and  indifference  which  betoken  organic  disease  of  the  brain  are  absent.  The 
attacks  are  not  of  long  continuance,  and  they  pass  away  entirely,  leaving  the 
patient  quite  cheerful,  to  return  again  in  a  week  or  fortnight. 

I  do  not  think  we  ought  to  make  a  mistake  in  diagnosis,  though  in  some 
cases  it  is  perplexing,  where  the  symptoms  are  not  so  marked  as  I  have 
described,  and  especially  in  very  young  children  about  the  period  of  their 
first  dentition,  in  whom  neuralgia  is  sometimes  met  with.  Nervous  affections 
and  general  increase  of  sensibility  are  common  enough  in  young  children 
about  this  time,  or  in  older  children  after  a  long  and  exhausting  illness,  as 
chronic  diarrhoea  or  typhoid  fever.  We  should  be  cautious  to  ascertain 
whether  the  pain  in  the  head  is  continuous  and  unremitting,  before  we  com- 
mit ourselves  to  an  opinion,  or  carry  out  any  plan  of  treatment.  Having 
made  out  our  diagnosis,  and  satisfied  ourselves  that  the  cerebral  tissue  is  not 
implicated,  we  do  not  in  any  way  become  anxious  about  a  neuralgic  seizure, 
for  though  it  robs  life  of  much  enjoyment,  it  does  not  tend  to  shorten  it, 
and  in  these  cases  it  passes  off  as  the  health  improves.  Severe  pain,  local 
and  either  continuous  or  recurrent,  if  attended  with  nausea,  vomiting,  or 
constipation,  ought  to  put  us  on  our  guard  against  meningitis  or  cerebral 


132  HEADACHES. 

tubercle;  nor  should  these  symptoms  delude  us  if  they  pass  off,  for  they  may, 
notwithstanding,  be  due  to  lurking  organic  mischief,  and  have  a  fatal  termi- 
nation at  no  distant  period.  Many  years  ago  I  met  with  an  instance  of 
headache  in  a  girl  fourteen  years  of  age,  chiefly  frontal,  which  had  continued 
on  and  off  for  months,  and  caused,  as  headaches  often  do,  no  anxiety  among 
the  parents.  When  the  head  was  very  painful,  the  child  was  kept  from 
school,  and  when  the  suffering  passed  away,  school-work  was  resumed,  the 
health  of  the  child  being  at  all  times  delicate.  After  the  headache  had 
troubled  her  more  or  less  for  a  year,  inflammation  of  the  meninges  accom- 
panied by  convulsions  set  in,  and  the  child  lost  her  life.  There  were  no 
gastric  symptoms  present  to  attract  attention  to  the  stomach,  and  the  head- 
ache, undoubtedly  due  to  cerebral  exhaustion  in  the  first  instance,  was 
followed  by  inflammatory  action  which  could  not  be  traced  to  tubercle. 

Treatment. — This  consists  in  enforcing  rest,  if  educational  zeal  has  been 
carried  too  far,  and  getting  the  general  health  amended  in  every  possible  way, 
that  the  nervous  tissue,  may  be  improved,  and  degenerative  changes  pre- 
vented. Quinine,  cod-liver  oil,  fresh  air,  and  absolute  rest  of  mind  and 
body,  are  important  at  this  early  period  of  life.  For  the  medical  treatment, 
the  plan  to  be  adopted  is  much  the  same  as  that  recommended  in  the  chapter 
on  neuralgic  headache  in  adults,  and  the  formulae  in  doses  suitable  to  the 
age  of  the  child  will  be  equally  appropriate.*  Dialyzed  iron,  either  in  the 
character  of  syrup,  or  an  aqueous  solution,  is  an  excellent  preparation  where 
it  is  sought  to  improve  the  quality  of  the  blood,  and  to  remove  the  anaemia 
(Form.  24  a).  As  it  is  almost  tasteless,  no  child  will  refuse  to  take  it,  and, 
unlike  many  other  preparations  of  iron,  it  is  readily  absorbed,  causing 
neither  indigestion  nor  constipation. 

(6)  Headache  depe7iding  on  some  intricate  Change  in  the  Cerebral  Mem- 
branes or  Tissues  of  the  Brain. 
This  condition  I  have  oftener  observed  among  hospital  out-patients  than 
in  private  practice.  The  children  are  generally  from  three  to  eight  years  of 
age  ;  they  gradually  fall  into  a  delicate  state  of  health,  and  cause  anxiety  in 
the  minds  of  their  parents.  In  some  cases  there  is  the  hereditary  tendency 
to  struma  and  consumption,  nervous  disease,  or  syphilis;  in  other  instances, 
irregular  and  drunken  habits  on  the  part  of  the  father  have  implanted  a  lia- 
bility in  his  child's  constitution  to  take  on  nervous  disorder.  Frontal  head- 
ache is  the  first  symptom  of  which  any  complaint  is  made;  the  child  is 
lethargic  and  indisposed  for  exertion,  the  mind  strays  and  wanders  from  any 
pursuit  or  occupation,  and  the  intelligence  is  dull  and  totally  incapable  of 
strain  or  concentration.  The  child's  disposition  is  much  changed  ;  if  he  has 
been  bright  and  cheerful  before  the  illness  overtook  him,  he  is  now  listless 
and  dull,  or  he  is  so  excitable  that,  if  thwarted  in  his  plans  or  wishes,  he 
becomes  exceedingly  fretful  and  quarrelsome.  When  playing  with  his  com- 
panions, he  is  liable  to  outbursts  of  passion,  and  goes  into  such  a  state  of 
frenzy  that  he  may  inflict  bodily  harm  on  those  about  him.  After  a  fit  of 
temper,  or  looking  over  a  book,  the  child  will  suddenly  become  drowsy,  and 
rest  his  head  on  a  table  or  chair,  and  fall  off  to  sleep.  It  is  the  sleep  of 
exhaustion,  but  quiet  and  profound;  the  skin  and  head  are  often  perspiring, 
and  when  he  awakes  he  is  unrefreshed.  At  night  he  is  restless,  tossing  off 
the  clothes,  and  in  the  morning  is  fretful  and  irritable,  as  though  the  sleep 
had  done  him  no  good.  The  pulse  is  soft  and  quiet,  occasionally  intermit- 
tent, but  there  is  an  absence  of  cardiac  disease;  there  is  no  sickness  and  no 

*  See  Chapter  XV.,  on  Neuralgic  Headache. 


HEADACHES    OF    CHILDHOOD    AND    EARLY    LIFE.  1 33 

elevation  of  temperature ;  the  tongue  is  clean,  and  the  bowels  regular,  or 
disposed  to  constipation.  In  fact,  it  is  not  a  condition  of  meningitis,  though 
there  is  no  reason  whatever  why  such  cases  in  pursuing  a  downward  course 
should  not  lead  to  inflammatory  mischief  in  the  brain  or  membranes.  Rather, 
the  tendency  is  to  cause  an  ansemic  state  of  the  blood  and  tissues,  and  an 
increase  of  serum  in  the  lateral  ventricles,  and  beneath  the  arachnoid,  or 
between  the  sulci  of  the  convolutions.  If  this  goes  on,  the  head  occasion- 
ally gets  larger  at  the  sides  and  more  prominent  at  the  forehead,  and  this 
appears  all  the  more  obvious  as  the  child  loses  flesh  and  the  face  shrinks.  In 
rickety  children  this  headache  is  not  uncommon,  and  recovery  is  the  more 
slow  and  tedious.  I  have  observed  it  among  boys  who  are  fond  of  school 
and  books,  particularly  if  they  are  of  a  nervous  or  sensitive  temperament, 
when  they  become  overanxious  with  their  studies,  and  this  worry  is  very  pre- 
judicial to  the  nervous  system.  If  the  health  is  naturally  delicate,  and  the 
food  unwholesome,  and  the  boys  are  deprived  of  air  and  exercise,  they  are 
the  more  likely  to  be  victims  to  this  form  of  suffering.  As  to  the  pathology 
of  this  affection,  there  can  be  no  doubt  of  its  being  one  of  exhaustion,  and 
the  cerebral  texture  is  more  exsanguine  and  less  firm  than  in  health.  I 
think  there  is  nothing  incompatible  with  recovery,  if  the  blood  improves  in 
quality,  and  the  brain  is  better  nourished.  Pure  air,  wholesome  food,  and 
proper  medicine  will  be  required.  Whilst  the  pain  lasts,  and  the  excitabil- 
ity of  the  nervous  centres  is  great,  there  is  no  remedy  like  bromide  of  potas- 
sium, combined  with  small  doses  of  belladonna,  and,  in  some  cases,  with 
iodide  of  potassium.  If  bark  or  quinine  is  ventured  on  too  soon,  the  head- 
ache returns  with  its  former  violence ;  and  the  same  will  happen  if  iron  or 
strychnine  is  had  recourse  to  before  the  brain  is  strong  enough  to  bear  a 
sudden  influx  of  blood  into  its  vessels. 

(7)  Organic  headache  in  children  arises  from  the  same  set  of  causes  as  in 
adults.  Any  morbid  growths  from  the  bone  or  membranes,  or  from  the 
white  or  gray  substance  of  the  brain  itself,  usually  induce  severe  pain  in  the 
head,  and  such  physiological  symptoms  as  serve  to  indicate  with  tolerable 
accuracy  the  situation  of  the  mischief.  Unfortunately,  the  condition  in  too 
many  instances  defies  all  treatment  from  medicine,  and  surgery  is  equally 
powerless.  Cancerous  or  fungoid  growths  may  spring  from  the  dura  mater, 
and  in  extending  outwards  cause  absorption  of  the  bone,  and  elevation  of 
the  tissues  of  the  scalp,  resembling  an  encysted  tumor.  When  interfered 
with,  they  cause  convulsions  and  death.  These  growths  rarely  implicate  the 
bones,  which  often  present  obstruction  to  their  progress,  but  at  times  the 
hardest  structures  do  not  oppose  the  direction  which  they  take.  Tumors 
having  this  perforating  tendency  may  also  grow  from  the  diploe,  and  even 
from  the  cellular  tissue  beneath  the  arachnoid  and  pia  mater,  and  from  the 
cerebral  substance  itself.  It  is  a  curious  fact  connected  with  these  tumors, 
that  they  often  attain  considerable  size  before  they  produce  any  disturbance 
in  the  functions  of  the  brain  ;  and  post-mortem  examination  has  occasionally 
revealed  their  presence  in  the  substance  of  the  brain,  when  no  symptoms  to 
attract  attention  to  the  brain  have  been  observed  during  life.  This  de- 
pends in  a  great  measure  on  the  situation  of  the  tumor,  for  one  which  is  im- 
bedded in  the  substance  of  either  hemisphere,  and  does  not  press  on  the 
sinuses,  or  falx,  or  tentorium,  is  less  likely  to  cause  pain  or  uneasiness.* 

*  A  case  is  related  by  Andral  where  an  osteo-fibroid  tumor  was  attached  to  the  tentorium, 
and  this  caused  such  pressure  on  the  cerebellum  as  to  diminish  its  volume,  and  change  its 
texture  into  one  of  extraordinary  hardness.  The  tumor  was  traced  to  a  fall  four  years  be- 
fore death,  and  the  leading  symptoms  were  no  uneasiness  at  the  time  of  the  accident,  but 
later  on  a  dull  pain  at  the  left  part  of  the  occipital  bone;  giddiness  from  time  to  time,  and 


1 34  HEADACHES. 

Even  a  cancerous  tumor  may  arise  as  a  primary  disease  in  the  brain  of  a 
child,  and  pursue  a  slow  and  tedious  course,  setting  up  no  disturbance,  un- 
less by  increasing  growth  or  pressure  it  should  involve  the  membrane  and 
excite  inflammation.  A  case  of  this  kind  is  related  by  Mr.  Solly,  in  a  child 
only  four  years  of  age.*  The  chief  symptoms  Avere  drowsiness  and  inactivity 
for  some  months,  followed  by  an  epileptic  seizure.  Under  the  use  of  mer- 
curials and  purgatives,  the  child  apparently  got  well,  but  after  a  time  he " 
became  again  sleeply  and  forgetful ;  his  intellect  was  impaired,  and  he  died 
at  the  end  of  six  months  from  the  time  of  the  epilepsy.  After  death  a  tu- 
mor was  found  in  the  posterior  lobe  of  the  left  hemisphere,  the  size  of  a 
hen's  egg.  Neither  the  membranes  nor  the  substance  of  the  brain  were 
more  vascular  than  usual.  Tubercular  tumors  of  the  brain  are  far  more 
common  in  the  case  of  children  than  the  other  varieties,  and  they  more  fre- 
quently involve  the  substance  of  the  hemispheres  and  cerebellum  than  the 
membranes  which  are  liable  to  inflammation  \  in  fact,  tubercle  of  the  brain  is 
very  prone  to  induce  inflammation  and  effusion  into  the  ventricles.  The 
symptoms  are  severe  headache,,  continuous  or  paroxysmal  :  then  passing  off, 
to  recur  again  with  convulsions,  insensibility,  and  coma.  After  death  it  is 
not  uncommon  to  meet  with  flattening  of  the  convolutions,  effusion  into  the 
ventricles,  and  a  hard  portion  of  yellow  tubercle,  varying  in  size  from  a 
marble  to  an  egg.  As  I  have  previously  mentioned, f  severe  headache  with 
vomiting,  constipation,  impairment  of  intellect,  convulsive  movements,  paral- 
ysis or  coma,  disturbance  of  vision,  etc.,  are  the  prominent  symptoms  of 
headache  due  to  organic  change. 

occasional  loss  of  consciousness  for  a  few  moments.  Later  on,  the  upper  extremity  of  the 
right  side  was  attacked  with  a  painful  tetanic  shock.  Five  or  six  of  these  shocks  followed 
each  other  rapidly,  and  then  intervals  of  months  elapsed ;  then  they  became  more  frequent, 
limited  to  the  nght  arm,  and  paralysis  of  this  limb  came  on,  at  first  transient,  and  afterwards 
more  complete.  The  right  lower  extremity  also  lost  the  power  of  motion,  but  there  was  no 
convulsive  movement. — Solly,  On  the  Brain,  p.  647. 

*  Solly,  On  the  Brain,  p.  648. 

•j- See  Chapter  XIV.,  on  Organic  Headache. 


FORMULA. 


(i)  R.     Potass.  Citrat.,  9j. 
Inf.  Digitalis, 
Inf.  Buchu,  aa  ^ss. 
Misce. — To   be   taken   three 
times  a  day. 
In  ursemic  headache,  with  deficient 
renal  action. 

(2)  R.     Potass.  Citrat.,  Qj. 

Spt.  Juniperi,  33. 

^ther.  Nitr.,  n^^xx. 
Decoct.  Scoparii,  §j. 
Misce. 
In  the  same  cases  as  the  above. 

(3)  R.     Potass.  Bitart.,  ^ss. 

Syr.  Limonis,  §ss. 
Aquje  ferventis,  Oij. 
Misce. 
To  be   taken  during  the  day  and 
night   in  the  same  cases,  where  the 
urine  is  scanty  and  the  bowels  sluggish. 

(4)  R.     Hydrarg.  Bichlorid.,  gr.  j. 

Tinct.  Ferri  Perchlor., 
Glycerini,  aa  gss. 
Aquae  purse,  ad  §xij. 
Misce. — A   tablespoonful    in 
an    equal  quantity 
of    water,   or   one 
ounce  of  Infusion 
of    Quassia,    three 
times  a  day. 
In  anasarca  and  ansemia,  where  the 
headache  is  due  to  renal  congestion, 
and  in  some  forms  of  syphilitic  head- 
ache when  the  cachetic  state  is  well 
marked. 

(5)  R-     Quinise  Disulph.,  gr.  x-gr. 

XV. 

Acid.  Sulph.  Dil.,  n\_x. 
Syrupi ,  gij. 


Aquae,  ad  gjss. 
Misce. 


(I 


To  be  taken  in  headache  from  ma 
larial  poisoning,  two  or  three  hours 
before  the  expected  paroxysm.  Af- 
terwards, a  third  part  three  times  a 
day  till  cinchonism  is  produced.  (Dr. 
Smith.) 

(6)  R.     Liquor.  Fowleri, 

Tinct.  Belladonnae,  aa^j. 
Aquae  purae,  ad  §jss. 
M.  Sig. — A  teaspoonful  in  a 
wineglassful       of 
water  three  times 
a  day. 
In  the  same  cases,  where  the  head- 
ache recurs  from  time  to  time. 

(7)  R-     Quiniae  Disulph.,  gss. 

Acid.  Arseniosi,  gr.  j. 
Nitric.  Dil.,  3J. 
Aquae  purse,  ad  §j. 
M.  Sig. — Thirty  drops   in   a 
wineglassful       of 
water  three  times 
a  day  after  food. 
In  similar  cases  to  the  above.     (Dr. 
Routh's  formula  for  giving  Arsenic.) 

(8)  R.     Liquor.  Cinchonae,  tt|^xx. 

Fowleri,  rr^v. 
Aquae  purae,  ad  5J. 
M.  Sig. — To  be  taken  three 
times  a  day  after 
food. 
In  neuralgic  headache  and  cerebral 
anaemia. 

(9)  R.     Liquor.  Fowleri,  3J. 

Tinct.  Quinis,  3jss. 
Mist.  Camph.,  ad  §vj. 
M.  Sig. — §ss  three  times  a  day 
in   a   little   water 
after  food. 
In  neuralgic  and  periodic  headache. 

35) 


136 


FORMULA. 


(10)   R.     Liquor.  Potass.  Ars.,  5J. 
Tinct.  Quinice,  5Jss. 
Hydr.  Bichlor.,  gr.  ss. 
Aquas,  ad  §vj. 
Misce. — A   tablespoonful    in 
a    wineglassful    of 
water  three  times  a 
day  after  food. 
In    neuralgic    headache,    where   a 
mercurial   is  desirable,   and  there  is 
the  history  of  syphilis. 


(11)  B.     Liquor.  Potass.,  Ars., 
Potass^,  aa  3]. 
Tinct.  Colchici,  ^ij. 

Lavand.  Co.,  ^iij. 
Aqu«  purse,  ad  gvj. 
Misce. — A   tablespoonful    in 
a    wineglassful    of 
water  twice  a  day 
after  food. 
In    neuralgic   headache   associated 
with  the  gouty  diathesis. 


(12)  B.     Tinct.  QuiniEe,  3xiv. 

Spt.  Chloroformi,  gij, 

Misce. — A     teaspoonful     in 

a    wineglassful    of 

water      twice      or 

three  times  a  day. 

In  neuralgic  and  nervous  headache. 


(13)  B.     Tinct.  Quinise,  ^vj. 

Potass.  Bromid.,  oJ^SU- 
Glycerini,  ^ij. 
Mist.  Camphorae,  ad  §vj. 
Misce. — A  sixth  part  twice  or 
three  times  a  day. 
In  neuralgic  and  nervous  headache. 


(14)  B.     Acid.  Hydrobromici,  ^vj. 
Quinise  Disulph.,  gr.  xij. 
Inf.  Gent.  Comp.,  ad  gxij. 
J^Iisce. — Two    tablespoonfuls 
twice  or  three  times 
a  day. 
In  neuralgic  and  nervous  headache, 
where  Quinme  alone  disagrees. 


(15)  B.     Sodse  Bicarb., 

Bismuth.  Subcarb., 
Pulv.  Acacise,  aa  jj. 
Spt.  Amm.  Arom.,  gij. 
Syr.  Zingib.,  ^iij.    _ 
Aquae  purae,  ad  gviij. 
Misce. — Two    tablespoonfuls 
three  times  a  day 
half  an  hour  before 
food. 
In  dyspeptic  headache  with  flatu- 
lence, acidity,  and  pyrosis. 

(16)  B.     Amm.  Carb.,  gr.  iv. 

Aquae,  gj. 
Misce. — To   be  taken  every 
three  or  four  hours. 
In  dyspeptic,  neuralgic,  and  nerv- 
ous headache,  and  in  some  forms  of 
gouty  headache. 

(17)  B.     Spt.  Amm.  Arom.,  ttlxI. 

Chloroformi,  rrLx. 
Aquae,  ad  ^j. 
Misce. — To   be  taken  every 
three  hours. 
In  dyspeptic  and^nervous  headache. 

(18)  B.     Sodae    Citro-Tart.    Efferv., 

3j-3ij.  (B.  P.) 
To  be  taken  whilst  effervesc- 
ing in  the  third  of 
a  tumblerful  of  cold 
water  early  in  the 
•   morning. 
As  a  mild  aperient  in  dyspeptic  or 
bilious    headache,    with    nausea   and 
sickness,  and  in  plethoric  headache. 

(19)  B.     Magnes.  Sulphat.,  3vj. 

Carb.,  5j. 
Tinct.  Lavand.  Co.,  giij. 
Aquae  Menth.  Pip.,  ad  gviij. 
Misce. — A   sixth   part  to  be 
taken  early  in  the 
morning,   and    re- 
peated as  may  be 
necessary. 
In  dyspeptic  and  bilious  headache 
with  flatulence. 


FORMUL/E. 


137 


(20)   R.     Quinise  Disulph.,  gr.  xij. 
Acid.  Sulp.  Dil.,  gss. 
T.  Ferri  Perchlor.,  .^^ij. 
Spt.  Chloroformi,  jij. 
Magnes.  Sulph.,  gjss. 
Syr.  Zingib.,^j. 
Aquae,  ad  ^xij. 
Misce. — Two    tablespoonfuls 
three  times  a  day. 
In  neuralgic  headache  with  consti- 
pation. 


(21)   R.     Syr.  Ferri  Phosph.  et  Quin. 

ise  et  Strychniae,  5Jss. 

Misce. — A    teaspoonful  in  a 

wineglassful  of 

water  three  times  a 

day  after  food. 

In  neuralgic  and  nervous  headache. 


(22)  R.     Syr.  Ferri  Hypophos.,  gjss. 

Misce. — A    teaspoonful   in  a 

wineglassful  of 

water  three  times  a 

day  after  food. 

In  neuralgic  and  nervous  headache, 

where  the  hypophosphites  are  useful, 

and  in  some  congestive  headaches. 


(22a)  R.    Syr.  Ferri  et  Calcii  Lacto- 
phosph.,  §ij. 
Misce. — One  or  two  teaspoon- 
fuls  in  a  wineglass- 
ful of  water  twice 
a   day  after  food. 
Fifteen  or  twenty 
grains  of  bromide 
of     potassium     or 
ammonium       may 
sometimes  be  add- 
ed to  each  dose. 
In  similar  cases  to  the  preceding 
marked  by  general  debility  and  de- 
fective nutrition. 


(23)  R.     Calcis  Hypophos.,  gr.  Ixxx. 
Tinct.  Ferri  Perchl.,  giij. 
Quinise  Disulph.,  gr.  xvj. 
Strychnise,  gr.  ss.-gr.  j. 
Spt.  Chloroformi,  gij. 


Syrupi,  §jss. 
Aquae  purae,  ad  gviij. 
Misce. — A  tablespoonful  to  be 
taken  three  times  a 
day  in  a  wineglass- 
ful of  water. 
In  similar  cases  to  the  above. 


(24)  R.     Ferri.  Citr.  et  Quinis,  353. 
Spt.  Chloroformi,  3J. 
Syr.  Aurant.,  giij. 
Aquae  purae,  ad  |vj. 
Misce. — A   sixth   part    three 
times  a   day  after 
food. 
In  neuralgic  and  nervous  headache, 
with  anaemia  and  depression,  and  in 
some  congestive  headaches.* 


(24a)  R.    Liquor.  Ferri  Dialysati,  51. 
Misce. — Ten  to  thirty  minims 
in    a    wineglassful 
of  water  twice  or 
three  times  a  day. 
In  similar  cases  to  the  preceding, 
and  especially  in   the  anaemic  head- 
ache of  children. 


(24^^)  R.    Ferri  Amm.  Citr.,  gij. 
Liq.  Potass.  Ars.,  n^xl. 
Syr.  Zingib.,  gss. 
Inf.  Calumbae,  ad  gviij. 
Misce. — Two    tablespoonfuls 
twice  a   day  after 
food. 
In  nervous  and  neuralgic  headache 
with  anaemia. 


(25)  R.     Amm.  Bromid.,  gj. 

Spt.  Amm.  Arom.,  gss. 
Aquae  purae,  ad  3Jss. 
Misce. — To  be  taken  on  ris- 
ing   in    the   early 
morning. 
In  some  forms  of  nervous  and  con- 
gestive headache. 

*  Three  to  five  drops  of  the  Liquor.  Strych- 
niae,  and  half  an  ounce  of  the  Tincture  of 
Calumba,  may  he  sometimes  added  to  this 
prescription  -with  advantage. 


I -.8 


FORMUL.'E. 


(25^;)  R.    Potass.  Bromid.,  3J. 

Spt.  iVmm.  Arom,  gij. 
Amm.  Carb., 
Sodse  Bicarb.,  aa  9ij. 
Syr.  Aurant,  ^iij. 
Aquae  purse,  ad  ^viij. 
Misce. — A  sixth   part  to  be 
taken     every    four 
hours  whilst  effer- 
vescing with  Acid. 
Citric,     gr.    xiv., 
dissolved    in    one 
tablespoonful       of 
water. 
In  the  early  stage  of  nervous  and 
neuralgic    headache   when    there    is 
nausea,  and  the  tongue  is  coated. 

(26)  R.     Potass.  Bromid.,  sij. 

Spt.  Amm.  Arom.,  giij. 
Mist.  Camph.,  ad  ^vj. 
Misce. — A   sixth   part    three 
times  a  day. 
In    nervous   and    neuralgic   head- 
aches, and  where  there  is  excitement 
and  irritability. 

(26c)  R.    Tinct.  Aconiti,  ^ss. 
Aquae  purse,  ad  giv. 
Misce. — A   teaspoonful    in  a 
tablespoonful       of 
water   every    half- 
hour  till    the  pain 
is  relieved. 
In  acute  congestive  headache,  with 
flushed  face  and  full  pulse. 

(27)  R.     Amm.  Chlorid.,  gr.  x-9j. 

Aquae  pur^,  ad  sjss. 
Misce. — To   be   taken   three 
times  a  day. 
In  neuralgic  and  nervous  headache, 
where  migraine  and  clavus  are  spe- 
cially marked. 

(28)  R.     Sodse  PI yphophosphitis,3ss. 

Inf.  Calumbse,  ad  gvj. 
Misce. — A  sixth  part   to  be 
taken    three    times 
a  day. 
In  neuralgic,  nervous,  and  anaemic 
headache. 


(29)  R.     Magnes.  Sulphat.,  5J. 

Quiniae  Disulph.,  gr.  viij. 
Acid.  Sulph.  Dil.,  n^^x. 
Inf.  Rosae  Co.,  ad  5viij. 
Misce. — Two    tablespoonfuls 
twice  or  three  times 
a  day  after  food. 
In  neuralgic  and  congestive  head- 
ache, with  constipation  and  full  habit. 

(30)  R.     Tinct.  Quiniae,  5vj. 

Spt.  Chloroformi,  3J. 
Mist.  Camph.,  ad  5VJ. 
Misce. — A   sixth   part    three 
times  a  day. 
In   gouty  and   nervous   headache, 
where  Quinine  is  necessary. 

(31)  R.     Potass.  Bicarb., 

Sodae  Bicarb.,  aa  3Jss. 
Vin.  Sem.  Colch.,  3J-3ij. 
Syr.  Zingib.,  §ss. 
Aquae,  ad  3viij. 
Misce. — Two    tablespoonfuls 
three  times  a  day, 
with      one     table- 
spoonful of  lemon- 
juice,  whilst    effer- 
vescing. 
In  gouty  headache,  and  the  head- 
ache of  cerebral  hyperemia. 

(32)  R.     Amm.  Carb.,  ^ss. 

Vin.  Sem.  Colch.,  gss. 
Tinct.  Aurant.,  gss. 
Aquae,  ad  §jss. 
Misce. — A  teaspoonful  in  half 
a      tumblerful     of 
Apollinaris     or 
Vichy  water  three 
times  a  day. 
In  gouty  headache. 

(33)  R.     Lithiae  Citrat.,  9ij. 

Potass.  Bicarb.,  sijss. 
Tinct.  Aurant.,  §ss. 
Aquae,  ad  §iv. 
Misce. — A   tablespoonful    in 
half  a  tumblerful  of 
water   three  times 
a  day. 
In  gouty  headache,  where  the  urine 
is  turbid,  and  contains  lithic  acid  in 
excess. 


FORMUL/E. 


139 


(34)  R.     Potass.  lodidi,  ^ss-.^j. 

Bicarb.,  gij. 
Vin.  Sem.  Colch.,  Ti^xl. 
Amm.  Carb.,  gr.  xxiv. 
Syr.  Zingib.,  §ss. 
Aquae,  ad  sviij. 
Two      tablespoonfuls      three 
times  a  day. 
In  rheumatic  headache. 

(35)  R.     Potass.  lodidi, 

Amm.  Hydrochlor.,aa3Jss. 
Inf.  Humuli.  ^vj.   . 
Misce. — A   tablespoonful 
three  or  four  times 
a  day  in   a  wine- 
glassful  of  water. 
In     rheumatic     headache.       (Dr. 
Smith.) 

(^6)  R.     Potass.  lodidi,  3J. 

Tinct.  Cinch.  Co.,  §j. 

Colch.,  3j._ 
Aquae  Cinnamomi,  ad  §xij. 
Misce. — Two    tablespoonfuls 
three  times  a  day. 
In  rheumatic  headache. 

(37)  R.     Potass.  lodidi,  gij. 

*  Liquor.    Hydr.    Bichlor. , 

pvj-gjss. 

Tinct.  Gent.   Comp.,  ^jss. 

Aquae  Cinnamomi,  ad  gxij. 

Misce. — Two    tablespoonfuls 

three  times  a  day 

in    a    wineglassful 

of  water  after  food. 

In  syphilitic  and  organic  headache. 

(38)  R.     Potass.  lodidi,  gj. 

Liq.  Arsenicalis,  gj. 
Tinct.  Quinis,  ad  5iij. 
Misce. — A     teaspoonful      in 
a    wineglassful    of 
water   three  times 
a  day  after  food. 
In  syphilitic  headache. 

(39)  R.     Tinct.  Ferri  Perchlor,  gijss. 

Acid.  Sulph.  Dil.  vel'Spt. 
Chloroformi,  .5J. 

*  The  mercury  may  be  omitted  according 
to  circumstances. 


Tinct.  Lavand.  Co.,  gvj. 
Syr.  Aurant.,  3SS. 
Mist.  Camph.,  ad  giv. 
Misce. — Two       teaspoonfuls 
three  times  a  day 
in  a  wineglassful  of 
water. 
In  nervous  headache  from  menor- 
rhagia.* 

(40)  R.     Potass.  Bromid.,  9j. 

Syr.  Tolutani,  gj. 
Aquae,  ad  gjss. 
Misce. — To   be   taken  every 
night  at   bedtime. 
As  a  sedative  in  the  pain  and  sleep- 
lessness  of    nervous    and    neuralgic 
headache. 

(41)  R.     Acid.  Hydrocy.  Dil.,  gss. 

Aquae,  ad  5Jss. 
Misce. — A     teaspoonful     in 
a  tablespoonful  of 
water  every  two  or 
three  hours. 
In  the  sickness  and  nausea  of  nerv- 
ous headache. 

(42)  R.     Acid.       Hydrocy.       Dil., 

ni^xxiv. 
Potass.  Bicarb.,  3J. 
Aquae,  ad  §vj. 
Misce. — Take   a   sixth    part, 
with   eight    grains 
of  Acid.  Citric,  dis- 
solved in  a  table- 
spoonful of  water, 
whilst  effervescing. 
In  similar  cases  to  the  preceding, 
and   in   the  sickness  and  acidity  of 
dyspeptic  headache. 

(43)  R.     Spt.  Chloroformi,  n\,x. 

Liquor.  Strychniae,  n^iv. 
Decoct.  Aloes  Comp.,  ad 
3jss. 
Misce. — To   be   taken    early 
every 'morning. 
In    the    constipation    of    nervous 
headache. 


'■•  One  of  the  prescriptions  containing  Arse- 
nic or  Ergot  may  be  necessary,  according  to 
the  discretion  of  the  practitioner,  or  either  of 
these  remedies  mav  be  added  to  the  Formula. 


I40 


FORMULA. 


(44)  R.     Acid.  Citric,  gijss. 

Quinice  Dis.,  gr.  xij. 
Syr.  Aurant.,  ^jss. 
Aquae  purse,  ad  gvj. 
Misce. 

R.     Potass.   Bicarb,  vel.   Sodse 
Bicarb.,  giij. 
Amm.  Carb.,  9ij. 
in  pulveres  xij. 
Signetur. — One  powder  to  be 
dissolved     in    a 
claretglassful    of 
water,    then 
mixed     with     a 
tablespoonful  of 
the  mixture,  and 
taken  three  times 
a  day  whilst  ef- 
fervescing. 
In  some  forms  of  nervous  headache 
where  there  is  nausea  and  depression. 


(45)   R.     Sodse  Bicarb.,  gjss. 

Spt.  Amm.  Arom.,  gij. 
Tinct.  Gent.  Comp.,  gss. 
Syr.  Aurant.,  §ss. 
Inf.  Gent.  Co.,  ad  gviij. 
Misce. — Two    tabiespoonfuls 
three  times  a  day. 
In  nervous  headache  with  dyspep- 
sia, furred  tongue,  and  acidity.  j 


!  Liquor  Strychniae,n|^xxxvj. 

j  Inf.  Quassise,  ad  gxij. 

I  Misce. — Two    tabiespoonfuls 

j  three  times  a  day. 

j      In  nervous  headache  with  a  clean 
tongue  and  slow  digestion. 

(48)  R.     Tinct.  Nuc.  A^om.,  jj. 
I  Acid.  Nitr.  Dil.,  3J. 

!  Hydrochl.  Dil.,  jij. 

Tinct.  Aurant.,  3vj. 
Aquse  pur^e,  ad  gvj. 
Misce. — A   tablespoonful    in 
a    wineglassful    of 
water  three  times  a 
day. 
In    nervous    headache   where    the 
Strychnia     does    not     agree.       The 
Liquor    Strychnine  sometimes  causes 
nervous     depression,     sickness,    and 
muscular  tremors,  which  I  have  occa- 
sionally noticed  as  the  effect  of  the 
Ferri  Citr.  et  Strychnise  in  gastralgia. 

(49)  R.     Tinct.  Digitalis,  ^ss.-gij. 

Mist.  Camphorse,  ad  ^vj. 
Misce. — A  sixth   part   to  be 
taken    three  times 
a  day. 
In  the  headache  of  cerebral  antemia 
as  a  cardiac  tonic,  when  the  pulse  is 
small  and  frequent,  or  there  is  palpi- 
tation. 


(46)  R.     *  Ferri  Amm.  Citr.,  ^ss. 

Acid.  Citric,  jj. 

Quinine  Sulph.,  gr.  vj. 

Aquce  purse,  ad  §vj. 
Misce. — A  sixth  part  to  be 
taken  three  times 
a  day  in  efferves- 
cence, with  Sodse 
Bicarb.,  gr.  x,  pre- 
viously dissolved 
in  a  tablespoonful 
of  water. 

(47)  R.     Acid.  Nitric.  Dil.,  ^j. 

Hydrochlor.Dil.,5ij. 

*  Three    to    five   minims   of    the    Liquor 
Strychnise  may  be  added  in  some  cases. 


(50)  R.     Tinct.  Digitalis,  jss.-jij. 

Spt.  Chloroformi,  5J. 
Syr.  Aurant.  Flor.,  3;iij. 
Aqute,  ad  svj. 
Misce. — A  sixth  part   to  be 
taken    three  times 
a  day. 
In  the  headache  of  cerebral  anaemia, 
where  depression   is    to   be   guarded 
against. 

(51)  R.     Inf.  Digitalis,  |vj. 

Misce. — Two  teaspoonfuls  to 
be      taken      three 
times  a  day. 
In  similar  cases  to  the  preceding, 
especially  if  accompanied  v/ith  dilata- 
tion, or  fattv  chana^e  of  the  heart. 


FORMULA. 


141 


(52)  B.     Tinct.  Bel]adonn3e,3ij-3iij. 

Nuc.  Vom.,  3j. 
Syr.  Zingib.,  §ss. 
Aquae,  ad  ^vj. 
Misce. — A   tablespoonful    in 
a    wineglassful    of 
water  three  times  a 
day. 
In  some  forms  of  anaemic  headache. 

(53)  B.     Strychnise  Sulph.,  gr.  ss. 

Tinct.  Ferri  Chlorid.,  gij. 
Glycerini,  gss. 
*Inf.  Gent.  Comp.,  ad  ^vj. 
(Dr.  Smith.) 
Misce. — A  tablespoonful  in  a 
wineglassful  of  wa- 
ter   three   times  a 
day  after  meals. 
In  the  headache  of  cerebral  ane- 
mia with  nervous  exhaustion.  • 

(54)  R.     Amm.  Carb.,  ^ss. 

Tinct.  Calumbs. 
Syr.  Aurant.,  aa  giij. 
Aquse.  purse,  ad  gvj. 
Misce. — A  sixth   part  to  be 
taken  twice  a  day. 
In  the  headache  of  cerebral  soft- 
ening. 

(55)  R.     Amm.  Carb.,  ^ss. 

Tinct.  Lavand.  Comp.,  ^ss. 

Calumbse,  giij. 
Mist.  Camph.,  ad  §viij. 
Misce. — Two    tablespoonfuls 
to  be  taken  three 
times  a  day. 
In  the  headache  of  cerebral  soften- 
ing with  irritability  and  depression, 
and  in  some  congestive  headaches. 

(56)  R.     Potass.  Bicarb.,  3J. 

lodidi,  gr.  xviij. 
Spt.  Amm.  Arom.,  giij. 
Mist.  Camph.,  ad  §viij. 
Misce. — A   sixth   part    three 

times  a  -day  after 

food. 

*  The  infusion  of  Quassia  or  Calumba  is 
preferable  to  Gentian,  in  consequence  of  the 
decomposition  of  the  iron  in  the  latter  prep- 
aration. 


In  organic  headache  due  to  syphi- 


lis. 


(57)  R.     Spt.   Chloroformi,  rriv. 

Liq.  Ergot.  Ext.,  n^xx-gss. 
Aqu^  purae,  ad  gj. 
Misce.— To  be   taken    three 
times  a  day. 
In  the  congestive  and  organic  forms 
of  headache  in  advanced  life. 

(58)  R.     Liq.  Ergot.  Ext.,  ^iij. 

Aquse,  ad  gvj. 
Misce. — Two  teaspoonfuls,  to 
be    gradually    in- 
creased to  two  ta- 
blespoonfuls, three 
times  a  day. 
In   congestive  headaches  from  or- 
ganic disease. 

(59)  R.     Sodae  Pot.  Tart.,  gij. 

Potass.  Bicarb.,  9j. 
Syr.  Aurant.,  gjss. 
Aquse,  ad  gjss. 
Misce. — The   draught  to  be 
taken  in   efferves- 
cence  with  Acid. 
Citric,  gr.  xv,  dis- 
solved in  a  table- 
spoonful of  water, 
early  in  the  morn- 
ing. 
In  dyspeptic   and  plethoric  head- 
ache. 

(60)  R.     Magnes.  Sulph.,  giij. 

Sodse  Bicarb.,  giij. 

Liquor  Taraxaci,  ^vj. 

Tinct.  Zingib.,  .^j. 

Aquse  pur«,  ad  .^vj. 
Misce. — A  sixth  part    to  be 
mixed  with  Acid. 
Tart.,    9j,    previ- 
ously dissolved  in 
a  tablespoonful  of 
water,    and    taken 
early  in  the  morn- 
ing whilst  efferves- 
cing. 
In  dyspeptic  and  plethoric  head- 
aches with  sluggish  liver. 


142 


FORMUL/E. 


(6i)  R.     Quiniae  Sulph.,  gr.  viij. 
Acid.  Citric,  gij. 
Aquae  purs,  ad  ^iv. 
Misce.  Sig. — No.   i  Mistura. 

R.     Sodae  Bicarb.,  ^iij. 
Liquor.  Taraxaci, 
Syr.  Aurant.,  aa  gss. 
Aquse  purae,  ad  5viij. 
Misce.  Sig. — No.  2  Mistura. 
One  tablespoonful  of 
No.  I  to  be  mixed 
with     two     table- 
spoonfuls   of   No. 
2,  and  taken  whilst 
effervescing  three 
times  a  day. 
In  similar  cases  to  the  above,  where 
Quinine  is  admissible. 


(62)  R.     Tinct.  Cinch.  Comp.,  gj. 
Spt.  Amm.  Arom.,  §ss. 
Misce. — A  teaspoonful    in  a 
wineglass ful  of 
water    three  times 
a  day. 
In  some   passive  congestive  head- 
aches, where  a  tonic  and   stimulant 
are  required. 


(63)  R.     Potass.  Bromid.,  53s. 
Tinct.  Cannabis  Ind., 

Hyoscyami,  aa,  gss. 
Aquas  purse,  ad  ^j. 
(Clouston.) 
Misce. — To  be  taken  at  bed- 
time. 
In  the  sleeplessness  of  hyperaemic 
headache. 


(64)  R.     Tinct.  Cannabis  Ind.,  n]^x. 
Potass.  Bromid.,  9j. 
Aqus  purae,  ad  3J5S. 
Misce. — To  be  taken  at  bed- 
time. 
In  the  sleeplessness  of  hypersmic 
headache. 


(65)  R.     Tinct.  Hyoscyami,  gss. 
Mist.  Camph.,  ad  §j. 


Misce. — To   be  taken  every 

night  at  bedtime. 

In  the  sleeplessness  of  nervous  and 

hyper aemic  headache. 

(66)  R.     Hydrat.  Chloral.,  9j. 

Aqus  purae,  ad  gjss. 
Misce. — To  be  taken  at  bed- 
time. 
In  the  headache  of  cerebral  hyper- 
emia and  vascular  excitement. 

(67)  R.     Hydrat.  Chloral., 

Potass.   Bromid.,  aa  gr.  x. 
Syr.  Rhoeados,  3J. 
Aque  purae,  ad  ^jss. 
Misce. — To  be  taken  at  bed- 
time. 
In  the  headache  of  cerebral  hyper- 
emia and  nervo-hyperaemic  headache 
with  nervous  excitement. 

(68)  R.     Potass.  Bromid.,  gij. 

Syr.  Aurant.,  ^ss. 
Inf.  Gent.  Comp.,  §iv. 
Aquae  purae,  ad  gvj. 
Misce. — A  sixth    part  to   be 
taken  three  times  a 
day. 
In  nervo-hyperaemic  headache  with 
loss  of  appetite  and  debility. 

(69)  R.     Potass.   Bromid. 

vel  Hydr.  Chloral.,  gr.  x. 
Nepenthe,  tt^^x. 
Aquae  purae,  ad  gjss. 
Misce. — To  be  taken  at  bed- 
time. 
In  the  sleeplessness  of  nervo-hyper- 
emic  headache. 

(70)  R.     Syr.  Hydrat.  Chloral.,  §jss. 

Misce. — One  teaspoonful  in  a 
wineglassful  of  wa- 
ter in  the  nervo- 
hypersmic  form  of 
headache  at  bed- 
time, or  in  the  day- 
time, when  the 
pain  is  severe,  till 
sleep  comes  on. 


FORMULAE. 


143 


(71)  B.     Ferri  Amm.  Citr.,  .5J. 
Potass.  Bromid.,  giij. 
vel  Amm.  Bromid.,  giij. 
Syr.  Zingib.,  §ss. 
Aquae  purae,  ad  gvj. 
Misce. — A  tablespoonful  in  a 
wineglassful  of  wa- 
ter twice  a  day,  at 
II  A.  M.  and  4  P.  M. 
In  the  headache  of  cerebral  anse- 


(72)  R.     Potass.   Bromid.,  9j. 

vel  Amm.  Bromid.,  5j. 
Tinct.  Valerian.  Co.,  gj. 
Syr.  Aurant.  Flor.,  gj. 
Aquae  Cinnamomi,  ad  §jss. 
Misce. — To  be  taken  twice  or 
three  times  a  day. 
In  some  forms  of  neuralgic  head- 
ache. 


(73)  R.     Pulv.   Ipecac.    Comp.,  gr. 
x-gr.  XV. 
Fiat  pulvis. — To  be  taken  at 
bedtime  in  gruel. 
In  rheumatic  headache. 


(76)  R.     Ferri  Sulphat., 

Pulv.  Zingib.,  aa  gr.  vj. 
Ext.  Aloes  Aquos., 
Quinise  Sulph. 
Saponis,  aa  gr.  xij. 
Misce  et  divide  in  pilulas  xij. 
— One  to   be    taken 
twice   a  day  after 
food. 
In  the  headaches  of  cerebral  anae- 
mia and  neuralgia,  where  the  bowels 
are  sluggish. 

(77)  R.     Ext.  Aloes  Barb.,  gr.  i^. 

Pulv.  Ipecac,  gr.  j. 
Pil.  Rhei  Comp.,  gr.  iij. 
Misce  et  fiat  pilula. — To  be 
taken  daily  before 
dinner. 
In  the  headache  of  cerebral  anae- 
mia and  dyspeptic  headache,   where 
intestinal  action  is  sluggish. 


(7S)  R.     Quinis  Sulph., 

Ext.  Aloes  Aquos. ,  aa  gr .  xij . 
Pulv.  Capsici, 

Ipecac,  aa  gr.  vj. 
Glycerini,  q.  s. 
Ut  fiant  pilulae  xij. — One  to  be 
taken  daily  before 
food,  at  midday. 
In  similar  cases  to  the  preceding, 
and  especially  in  women  with  small 
assimilative  power. 

Vel.    R.     Ext.  Nuc  Vom.,  gr.  ss. 
Pil.  Rhei  Comp.,  gr.  iij. 
Pulv.  Capsici,  gr.  y^. 
Misce  et  fiat  pilula. — To  be 
taken  daily  at   12 
o'clock.     (Samari- 
tan Hospital.) 
An  excellent  pill  to  keep  the  bow- 
els regular  in  nervous  headache,  where 
the  muscular  fibre  of  the   intestines 
requires  stimulation. 

(79)  R.     Hydr.  Subchlorid.,  gr.  iij. 

Pil.  Coloc  Co.,  gr.  vj. 

Ext.  Hyoscyami,  gr.  ij. 
Misce  et  divide  in  pilulas  ij. 
— To  be  taken  at  bed- 
time  occasionally. 
As  a  cholagogue  cathartic  in  dys- 
peptic, bilious,  and  gouty  headache. 

(80)  R.     Pulv.  Scammonii,  9j. 

Ext.  Coloc.  Co.,  5j. 

Hydr.  Subchlorid.,  gr.  xij. 

01.  Carui,  tt^x. 
Misce  et  divide  in  pilulas 
xviij. — One  or  two 
occasionally  at 
bedtime,  in  similar 
cases  to  the  pre- 
ceding. 

(81)  R.     Pil.  Hydrarg.,  gr.  xij. 

Rhei  Comp.,  gss. 
Ext.  Hyoscyami,  gr.  x. 
Misce  et  divide  in  pilulas  xij. 
— One  or  two  at  bed- 
time twice  a  week. 
In  dyspeptic  headache,  and  in  the 
headaches   of    advanced   life   with  a 


144 


FORMULA. 


(82)  B.     Hyd.  c.  Creta,  gr.  xij. 

Ext.  Hyoscyami,  gr.  x. 
Pil.  Rliei  Comp.,  Qij. 
Misce  et  divide  in  pilulas  xij. 
— One  or  two  occa- 
sionally at  bedtime. 
As  an  alterative  in  dyspeptic  head- 
ache. 

(83)  R.     Ferri  Sulphat., 

Quinise  Sulph.,  aa  gr.  xij. 
Pulv.  Rhei,  gr.  ix. 
Zingib.,_gr._vj. 
Misce  et  divide  in  pilulas  xij. 
— Take     one     three 
times  a  day. 
In  neuralgic  headache  and  atonic 
dyspepsia  with  flatulence. 

(84)  B.     Pil.  Aloes  etAsafoetid.j^ij. 

In  pilulas  xij. — One  or  two  at 
bedtime    every 
night. 
In  nervous  headache  with  flatulence 
and  constipation. 

(85)  B.     Pil.  Aloes  et  Ferri,  ^j. 

In  pilulas  xij. — One  or   two 
at    bedtime   every 
night.    • 
In  neuralgic  and  nervous  headache 
with  constipation. 

(86)  R.     Pil.  Aloes  et  Myrrhse,  3J. 

Ferri  Sulphat.,  gr.  vj. 
Misce  et  divide  in  pilulas  xij. 
— Two    occasionally 
at  bedtime. 
In   nervous   or   ansemic   headache 
with  torpid  colon. 

(87)  R.     Zinci  Valerian.,  gr.  xij. 

Pulv.  Rhei,  gr.  xx. 

Zingib.,  gr.  vj. 
Ext.  Gentian,  gr.  xij. 
Misce  et  divide  in  pilulas  xij. 
— One   to   be   taken 
three  times  a  day. 
In  neuralgic  headache. 

(88)  R.     Phosph.  Pur., 

Strychnice,  aa  gr.  j. 
Conf.  Rosse,  q.  s. 


Ut  fiant  pilute  1. — Take  one 
three  times  a  day. 
In  some  forms  of  neuralgic  head- 
ache. 

(89)  R.     Phosph.  Pur.,  gr.  j. 

Conf.  Rosae,  q.  s. 
Ut  fiant  plulse  xxxvj. — Take 
one  three  times  a 
day. 
In  similar  cases  to  the  preceding.* 

(90)  B.     Phosph.  Pur.,  gr.  j^. 

Ferri  Redact.,  gr.  xx. 
Ext.  Nuc.  Vom.,  gr.  ij. 
Misce  et  divide  in  pilulas  viij. 
— One   to   be   taken 
twice  a  day. 
In  neuralgic  headache,  f 

(91)  R.     Phosph.  Pur.,  gr.  j. 

Quiniae  Sulph., 
Ferri  Sulph.,  aa  gr.  xvj. 
Ext.  Rhei,  5j. 
In  pilulas  xxxvj. — One  to  be 

taken  three  times  a 

day. 

(92)  B.     Ext.  Cannabis  Ind.,  gr.  y( 

-gr-  j- 
Conf.  Rosse,  q.  s. 
Ut  fiat  pilula. — To  be  taken 
at  bedtime. 
In   the   sleeplessness   of  neuralgic 
headache. 

(93)  R.     Pulv.  Camphor.,  gr.  ij. 

Ext.  Hyoscyami,  gr.  ij. 
Misce  et  fiat  pilula.— To  be 
taken  at  bedtime. 
In  the  sleeplessness  of  nervous  and 
neuralgic  headache. 

*  Perles  of  Phosphorus  are  manufactured 
by  Messrs.  Corbyn,  Stacey  &  Co.,  of  London, 
each  Perle  containing  gr.  J^,  gr.  J^ ,  gr.  yi^. 
They  are  hermetically  closed  in  a  covering  of 
gelatin,  and  the  dose  and  effect  of  the  rem- 
edy may  be  relied  upon.  ^Vllen  Phosphorus 
is  prescribed  alone,  the  Perle  is  the  best 
method  of  administering  it. 

■j-  These  prescriptions  may  be  varied  accord- 
ing to  the  state  of  the  patient;  Valerianate  of 
Zinc  and  Cannabis  Indica  may  sometimes  be 
added, 


FORMULAE. 


145 


(94)   B.     Podophyllin,  gr.  iv. 

Pil.  Hydrarg.,  gr.  viij. 
Ext.  Hyoscyami,  gr.  xvj. 
Misce  et  divide  in  pilulas  viij. 
— Take     one     every 
night. 
In  gouty  headache. 


(95)  R.     Pil.  Coloc.  c.  Hyos.,  3J. 

In  pilulas  xij.— One  or  two  at 
bedtime  occasion- 
ally. 
In  nervous  headache,  when  an  ac- 
tive aperient  is  required. 


(96)  R.     Ext.  Colocynth,  ^ij. 
Rhei, 
Pulv.  Scammonii,  aa  gr.  x. 
In  pilulas  xij. — Take  one  oc- 
casionally at  bed- 
time. 
In  nervous  or  dyspeptic  headache 
as  an  active  aperient. 


(97)  R.     Zinci  Valerian., 
Ferri  Sulph., 
Ext.  Rhei,  aa  gr.  xvj. 
Misce  et  divide  in  pilulas  xvj. 
— One    to   be   taken 
three  times  a  day. 
In  nervous  headache. 


(97a)  R.    Zinci  Sulph.,  gr.  j. 

Ext.  Nuc.  Vom.,  gr.  ss. 
Conf.  Rosse,  q.  s. 
Ut  fiat  pilula. — To  be  taken 
twice  a  day. 
In  nervous  headache. 


(98)   R.     Zinci  Oxyd.,  gr.  ij. 
Conf.  Ros^,  q.  s. 
Ut  fiat  pilula. — To  be  taken 
three  times  a  day. 
In  nervous  headache. 


(99)  R.     Pil.  Rhei  Comp.,  gj. 

In  pilulas  xij. — Take  one  ev- 
ery night. 


As  a  mild  aperient  in  nervous  and 
dyspeptic  headache. 


xij. 


(100)  R.     Pulv.  Ipecac,  gr.  vj. 
Ext.  Aloes  Barb.,  gr. 

Taraxaci,  ^ss. 
Saponis,  gr.  x. 
Misce  et   divide  in   pilulas 
xij. — Take  one  ev- 
ery night,  or  before 
dinner  daily. 
As  a  laxative  in  nervous  headache 
to  assist  digestion. 


(loi)  R.     Pulv.  Myrrhse, 

Rhei,  aa  gr.  xvj. 
Pil.  Aloes  Barb.,  gr.  xij. 
Ext.  Anthemidis,  ^ss. 
01.  Caryophylli,  itlv. 
Misce  et  divide  in  pilulas  xx. 
— One  or  two  daily 
before  the  midday 
meal. 
As  a  dinner  pill   in   nervous  and 
dyspeptic  headache  to  assist  digestion. 


(102)  R.     Ext.  Opii, 

Pulv.  Rhei,  aa  gr.  j. 
Pil.  Coloc.  Co.,  gr.  jss. 
Misce  et  fiat  pilula. — To  be 
taken  every  night. 
In    the    sleeplessness    of    anaemic 
headache. 


(103)  R.     Ext.  Gentian., 
Ferri  Sulph., 
Pulv.  Digitalis,  aa  gr.  xij. 
Cinnamomi,  gr.  vj. 
Misce  et  divide  in  pilulas  xij. 
— Take     one     three 
times  a  day. 
In    the   headache  of  cerebral   an- 
aemia,   where   Digitalis   is    required. 
Where  there  is  unsteadiness  of  the 
heart's  action  after  food,  and  there  is 
flatulence,  the  iron   may  be   advan- 
tageously omitted,  and  Pulv.  Zingib. 
substituted  for  Pulv.  Cinnamomi. 


146 


FORMULAE. 


(104)  R.     Ext.  Belladonnje,  gr.  vj- 

gr.  xij.         _ 

Ext.Glycyrrhizse,  gr.xxiv. 

Misce  et  divide  in  pilulas  xij. 

— Take     one     every 

night,  or  night  and 

morning,   but   the 

remedy    must     be 

carefully  watched.* 

In  the  headache  of  cerebral  anaemia. 

(105)  R.     Zinci  Valerian,  gr.  viij. 

Ext.  Humuli,  gr.  xx. 
Rhei,  gr.  viij. 
Misce  et   divide   in   pilulas 
viij.  —  Take     one 
every  night. 
In  some  forms  of  organic  headache 
and  cerebral  softening,  where  there 
is  irritability  and  sleeplessness. 

(106)  R.     Ext.  Aconiti,  gr.  vj. 

Hyoscyami,  gr.  xviij. 
Ant.  Pot.  Tart.,  gr.  j. 
Misce  et  divide  in  pilulas  vj. 
— Take     one     every 
night. 
In  the  headache  of  active  cerebral 
hypersemia,  where  depressants  are  re- 
quired. 

(107)  R.     Bismuth.  Subcarb.,  9j. 

To  be  taken  in  a  wineglass- 

ful  of  water  twice 

a  day  before  meals. 

In  subacute  congestive   headache, 

with  flatulence  and  discomfort  after 

food. 

(108)  R.     Zinci  Sulph.,  gr.  v. 

Aquge  purse,  gjss. 
Fiat  haustus. — To  be  taken 
as  an  emetic,  fol- 
lowed by  drinking 
freely     of      warm 
water  till  vomiting 
ensues. 
In  some  forms  of  bilious  and  nerv- 
ous headache. 

*  See  the  effects  of  an  overdose  in  Chapter 
I.,  on  the  Headache  of  Cerebral  Anaemia. 


(109)  R.     Pulv.  Ipecac,  9j. 
Aquae  puree,  §jss. 
Fiat  haustus. 
In  the  same  cases  as  the  preceding. 

(no)  R.     Ext.  Belladonna,  gr.  v. 
To  be  rubbed  into  the  af- 
fected temple  every 
night. 
In    nervous    headache,    migraine, 
clavus,  etc. 

(in)  R .     Ung.  Veratria;,  3J.  (B.  P.) 
A  little  to  be  rubbed  into 
the  affected  temple 
till  the  pain  is  re- 
lieved. 
In    neuralgic   and   some   forms   of 
nervous  headache,  where  the  pain  is 
localized. 

(112)  R.     Ung.  Aconiti^,  3J.  (B.  P.) 

To  be  used  in  the  same  way, 
and  for   the  same 
cases   as    the   pre- 
ceding. 
Ung.    Aconitinse    (Flem- 
ing). 

(113)  R.     Aconitinse,  gr.  xvj, 

Spt.  Vini  Rect.,  ttlxvj. 
Rub  together,  and  then  add 
carefully  one  ounce 
of  lard.  It  may  be 
used  in  the  same 
cases  as  the  preced- 
ing. (A  very  ex- 
pensive applica- 
tion.^ 

(114)  R.     Ext.  Aconiti  Alcohol.,  3j. 

Adipis,  gij. 
Misce  et  fiat  unguentum. — 
To  be  used  in  the 
same  cases  as  the 
preceding.  {Much 
less  expensive. '^^ 


*In  using  all  these  ointments,  care  is  re- 
quired to  apply  very  small  quantities,  and 
never  to  the  broken  skin.  A  tingling  sensa- 
tion commonly  precedes  the  cessation  of  the 
pain. 


FORMULA. 


147 


(ii4<a!)  R.    Ung.Hyd.Nit.0xyd.,3Jss. 
Adipis  Benz.,  3ijss. 
Misce. — A  piece  the  size  of 
a  small  nut  to  be 
rubbed    into   the 
scalp    night    and 
morning. 
In  pityriasis  of  the  scalp. 

(115)  R.     Quinise  Sulph.,  gr.  x. 
Acid.  Sulph.  Dil.  n^x. 
Aquae,  ad  ni^c. 
Misce. — To  be  injected  in 
severe  cases.* 


*  The  acid  in  this  gives  rise  to  pain  and  in- 
flammation, sometimes  even  to  a  troublesome 
boil  or  abscess.  The  neutral  sulphate  is  sol- 
uble without  acid,  and  does  not  produce 
local  irritation. 


(Surgeon-Major  A.  R.  Hall's  for- 
mula for  the  subcutaneous  injection  of 
Quinine  in  the  hyperpyrexia  of  sun- 
stroke.) 

(116)  R.     Morph.  Acet.,  gr.  x. 
Atropi^  Sulph.,  gr.  j. 
Aquse  destill.,  gij. 
Misce. 
Formula  for  the  hypodermic  injec- 
tion   of    Morphia.      Twelve   minims 
contain  one  grain  of  Morphia. 


Many  of  the  preceding  Formula 
are  suitable  for  children  in  diminished 
doses  proportioned  to  age. 


INDEX.  • 


Aconitina  ointment  in  nervous  and  neuralgic  headache, 

79)  i^t^. 
Aconite  in  congestive  headache,  60. 

cerebral  hyperaemia,  40. 
Active  hyperaemia,  33. 
Advanced  life,  headache  of,  105. 

treatment  of,  105. 
Alcohol  in  cerebral  anaemia,  27. 

Aloes,  compound  decoction  of,  in  nervous  headache,  78. 
Ammonia,  carbonate  of,  in  nervous  headache,  96,  103. 
Ammonium,  bromide  of,  in  congestive  and  nervous 
headache,  60. 

chloride  of,  in  neuralgic  headache,  112. 
Anaemia,  cerebral,  16. 

vascular  conditions  in,  18. 

symptoms  of,  23. 

prognosis  of,  24. 

treatment  of,  24. 

chronic,  21. 
Antimony  m  hyperaemic  headache,  40. 
Arsenic  in  malarial  and  neuralgic  headache,  92, 112. 
Arthritic  headache.     See  Gouty  Headache,  94. 
Atheromatous  change,  headache  in,  103. 

Bebeerin,  113. 
Belladonna,  25. 

Bernard,  Professor,  experiments  of,  45,  46. 
Bilious  Headache.     See  Dyspeptic  Headache,  50. 
Blood-letting  in  congestive  headache,  59. 
Blood-supply,  relation  of  tissues  to  their,  39. 
Body-snatcher's  headache,  89. 
Brain,  concussion  of,  125. 

vascular  supply  of,  17. 
Bromide  of  potassium  in  congestive  headache,  60. 

nervous  headache,  77. 
Brown-Sequard's  experiments,  45,  46. 
Burrows,  Sir  G.,  experiments  of,  16. 

Cannabis  Indica,  41. 

Causes  of  increased  activity  of  the  nervous  system,  9. 
Cerebral  circulation,  16. 
anaemia,  17- 

experiments  to  produce,  16,  17. 
vascular  condition  of,  18. 
symptoms  of,  23. 
prognosis  of,  24. 
treatment  of,  24. 
alcohol  in,  27. 
hyperaemia,  31. 
forms  of,  32. 

with  inflammatory  fever,  32. 
active,  34. 
in  the  gouty,  34. 

from  weakness  of  cerebral  vessels,  35. 
passive,  36. 
symptoms  of,  37. 
treatment  of,  40. 
Cerebro-spinal  fluid,  17. 
Chapman's,  Dr.,  spinal  ice-bag,  43. 
Childhood,  headaches  of,  115. 
cerebral  headache  in,  125. 
treatment  of,  127. 
Childhood,  gastric  headache  in,  127. 
epileptic  headache  in,  128. 

treatment  of,  129. 
febrile  headache  in,  129. 
neuralgic  headache  in,  130. 
Childhood,  neuralgic  headache  in,  treatment  of,  132. 
headache  due  to  tissue  change  in,  132. 
organic  headache  in,  133. 
Children,  training  of,  115. 
overtaxation  of,  116. 


Chloral  hydrate,  cautions  as  to  use  of,  84. 
Chronic  cerebral  anaemia,  21. 
Cod-liver  oil  in  nervous  headache,  81. 
Cold,  use  of,  in  cerebral  hyperaemia,  42. 
Congestive  headache,  56. 
in  plethoric  persons,  56. 
due  to  acute  congestion,  57. 
from  mental  causes,  57. 

asthma,  whooping-cough,  bronchitis,  58. 
hypertrophy  and  valvular  diseses  of  heart,  58. 
.     organic  changes,  58. 
epilepsy,  59. 
effects  of,  upon  the  disposition,  S9- 
treatment  of,  59. 
Cranium,  anatomical  peculiarities  of,  44. 
Croton-chloral,  114. 

Depressant  remedies,  40. 

Determination  of  blood  to  the  head,  33. 

Diet  in  plethoric  headache,  63. 

Digitalis,  25. 

Disturbances  of  vision  in  nervous  headache,  68. 

Dysmenorrhaea,  a  cause  of  headache,  67. 

in  nervous  headache,  70. 
Dyspeptic  headache,  50. 

action  of  the  vagus  in,  50. 

commencement  of,  53. 

causes  of,  54. 

treatment  of,  55. 

emetics  in,  55. 

calomel  in,  55. 

alkalies  in,  55. 
Dyspeptic  headache,  bismuth  and  nux  vomica  in,  55. 

aconite  in,  55. 

Early  life,  headaches  of,  115. 

brain  repose  in,  119. 

hypertrophy  of  brain  in,  121. 

attendance  at  school  in,  122. 
Emotion,  effects  of,  upon  the  gastric  juice,  53. 
Epilepsy  from  tapeworms,  51. 
Epileptic  headache  in  children,  128. 
Ergot  in  headache,  41,  106. 
Experiments  of  Mr.  Durham,  22. 
Eye,  pain  in  the,  70. 

Febrile  headache  in  children,  129. 

treatment  of,  130. 
Fecal  fermentation,  headache  from,  88. 
Fever,  imflammatory,  52. 
Fevers,  headache  in,  85. 
Friedrichshalle  water,  40. 

Gas-poisoning,  headache  from,  88. 
Gastric  headache  in  children,  127. 
Gelseminum,  tincture  of,  113. 
Gouty,  cerebral  hyperaemia  in  the,  34. 

hyperaemia,  state  of  vessels  in,  34,  35. 

or  arthritic  headache,  94. 

physical  symptoms  of,  94. 
in  the  cachectic,  95. 

headache,  treatment  of,  96. 
Guarana  in  nervous  headache,  79. 

action  of,  on  vasomotor  nerves,  79. 

Hair  affected  in  nervous  headache,  76. 
Headache,  causes  of,  9. 

from  tissue  change  in  children,  132. 
Headache  from  disorder  of  liver,  50. 
Hearing,  acuteness  of,  in  neuralgic  headache,  108. 
Hemicrania  in  renal  cirrhosis,  iii. 
Hunyadi  Janos  water,  40. 


(148) 


INDEX. 


149 


Hydrate  of  chloral,  84. 

cautions  as  to  the  use  of,  84. 
Hydrocyanic  acid  in  nervous  and  sick  headache,  78. 
Hypersemia,  cerebral,  31. 

forms  of,  32. 

with  inflammatory  fever,  32. 

active,  34. 

in  the  gouty,  34. 

passive,  36. 

symptoms  of,  37. 

treatment  of,  40. 

use  of  cold  in,  42. 

from  intellectual  strain,  39. 

irritability  in,  34. 
Hyperpyrexia,  with  headache,  37. 
Hypertrophy  of  brain  in  children,  121. 
Hypodermic  injections  in  nervous  headache,  80. 
Hypophosphite  of  soda  in  neuralgic  headache,  112. 
Hypophosphites  of   quinine,  strychnia,  and   iron  in 
neuralgic  headache,  112. 

Ice-cap  in  hyperaemia,  43. 

Iodide  of  potassium  in  syphilitic  headache,  100. 

Iron,  dialyzed  solution  of,  132. 

Lactophosphites  of  iron  and  lime,  112, 137. 

Leucorrhoea  a  cause  of  neuralgic  headache,  108. 

Lithia,  salts  of,  40,  96. 

Liver,  disorder  of,  headache  in,  50. 

Local  hyperaemia  of  the  brain,  20. 

Malarial  headache,  treatment  of,  90. 
Menorrhagia  as  a  cause  of  headache,  67,  108. 
Mental  causes  of  congestive  headache,  57. 
Mercury,  bichloride  of,  in  syphilitic  headache,  100. 
Migraine,  75. 

Morson's  pepsin  wine  in  nervous  headache,  81. 
Mustard  poultice  in  nervous  headache,  78. 

Nervo-hyperasmic  headache,  82. 
symptoms  of,  82. 
at  the  menopause,  83. 
treatment  of,  83. 
chloral  in,  84. 
Nervous  headache,  64. 
means  to  avert,  65. 
causes  of,  65. 
malaria,  66. 
symptoms  of,  66. 
constipation  in,  67. 
disturbance  of  vision  in,  68 . 
cases  of,  6g,  71,  72,  73. 
occasional,  73. 
continuous,  73. 
effects  of,  on  scalp,  76. 
treatment  of,  76. 

preventive,  77. 

palliative,  77,  78. 
belladonna  and  aconitina  ointment  in,  79. 
Neuralgic  headache,  107. 

oversensibility  to  sound  in,  108. 
menorrhagia  as  a  cause  of,  108. 
causes  of,  108. 
cases  of  toothache  in,  109. 
Dr.  Anstie's  case  of,  iii. 
treatment  of,  112. 

belladonna  and  aconitina  ointment  in,  112. 
chloride  of  ammonium  in,  112. 
quinine  and  arsenic  in,  113. 
in  children,  r3o. 
Nux  vomica  in  nervous  headache,  81. 

Occipital  headache,  49. 

Opium,  25. 

Organic  or  structural  headache,  loi . 

lack  of  symptoms  in,  101. 

symptoms  of,  102. 

causes- of,  103,  104. 

treatment  of,  104. 

in  children,  133. 
Ovarian  irritation,  67. 

Oversuckling,  a  cause  of  nervous  headache,  67. 
Overtaxation  of  children,  116. 
Oxide  of  zinc,  79. 

silver,  79. 


Pain,  sympathetic,  12. 

Periosteum,  headache  in  disease  of  the,  99. 

treatment  of,  100. 
Perivascular  spaces,  17. 
Phosphorus,  92. 
Phosphorus,  paries  of,  144. 

in  neuralgic  headache,  113. 
Plethoric  headache,  61. 

symptoms  of,  62. 

treatment  of,  62. 
Podophyllin,  96. 
Potash,  salts  of,  40. 
Potassium,  iodide  of,  25. 

in  syphilitic  periostitis,  99. 

bromide  of,  in  congestive  and  nervous  headache 
60,  78. 
Prodromata  of  headache,  13. 
Psychical  symptoms  in  gouty  headache,  95. 
Pullna  water,  40. 

Quinine,  37. 

subcutaneous  injection  of,  in  sunstroke,  37. 
large  doses  of,  in  malarial  headache,  90. 
and  arsenic  combined,  113. 

Relapsing  fever,  headache  in,  85. 
Relation  of  tissues  to  thetr  blood-supply,  39. 
Renal  cirrhosis,  headache  in,  iii. 
Rest  in  brain  affections,  14. 
Rheumatic  headache,  97. 
treatment  of,  97. 

Saline  aperients  in  plethora,  63. 

School  attendance  of  children,  122. 

Sedative  remedies  in  cerebral  hyperaemia,  41. 

Senna,  89. 

Sleep,  state  of  the  brain  in,  22. 

Soda-water  and  champagne  in  nervous  and  sick  head-- 

ache,  78. 
Structural  headache.     See  Organic  Headache,  loi. 
Strychnia,  80. 
Sulphate  of  zinc,  145. 
Sunstroke,  severe  symptoms  due  to,  37. 
Supraorbital  neuralgia,  70. 

in  children,  130. 
Symonds,  Dr.,  experiments  of,  16. 
Sympathetic  headache,  44. 

vasomotor  nerves,  relation  of,  to,  44. 

visceral  relations  of,  44. 

from  ovarian  irritation,  47. 

pain,  12. 
Symptoms  of  cerebral  anaemia,  23. 

hyperaemia,  37. 
Syphihs  as  a  cause  of  headache,  99. 
Syrup  of  buckthorn,  89. 

Tamar-Indien,  89. 

Teeth,  diseased,  as  a  cause  of  headache,  109. 

Thalami  optici,  functions  of,  10. 

Tissues,  relation  of,  to  blood-supply,  39. 

Toxaemic  headache,  85. 

in  acute  fever,  85. 

from  uraemia,  87. 

carbonic  acid  poisoning,  88. 

treatment  of,  89. 
Training  of  children,  i-is. 
Tumors  of  the  brain,  102,  134, 

Uraemic  headache,  87. 

treatment  of,  8-7. 
Urine,  limpid,  in  nervous  headache,  66. 

Vagus,  action  of,  on  stomach,  52-. 

Varieties  of  headache,  15. 

Vasomotor  nerves  of  viscera,  44. 

Vertical  headache,  23. 

Vision,  disturbances  of,  in  nervous  headache,  68. 

Waters,  mineral,  in  congestive  headache,  41. 

Xanthelasma  palpebrarum,  76. 

Zinc,  oxide  of,  79. 

valerianate  of,  in  nervous  headache,  78,  113. 
sulphate  of,  78. 


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would  fall  upon  the  book  before  us  without  any  kind  of  hesitation." —  West.  Jour,  of  Med.  and  Surgery 

"We  do  not  hesitate  to  say,  that  it  is  now  the  most  complete  and  best  treatise  on  the  subject  in  th* 
English  language." — Buffalo  Medical  Journal. 

"We  know  of  no  work  on  this  all-important  branch  of  our  profession  that  we  can  recommend  to  th« 
undent  or  practitioner  as  a  safe  guide  before  this." — Chicago  Medical  Journal. 


yUST  PUBLISHED. 

■  A  PRACTICAL  TREATISE 

ON   THE 

Diseases  of  the  Uterus^ 

OVARIES,  AND  FALLOPIAN  TUBES. 

By   A.    COURTY,    M.D., 

Professor  of  Clinical  Surgery,  Montpellier. 

TRANSLATED  FROM  THE  THIRD  EDITION,  BY  HIS  PUPIL  AND  ASSISTANT, 

AGNES    M'LAREN,   M.D.,  M.K.Q.C.P.I., 

WITH  A  PREFACE  BY 

MATTHEWS    DUNCAN,  M.D.,  LL.D.,  F.R.S.E., 

Obstetric  Physician  to  Saint  Bartholonnew's  Hospital,  London. 

WITH  FOUR  HUNDRED  AND  THIRTY-ONE  ILLUSTRATIONS 

ONE  VOLUME,  OCTAVO. 

Price,  handsome  cloth,  $6.00;  full  sheep,  raised  bands,  $7.00. 


EXTRACT    FROM    PREFACE. 

Among  books  devoted  to  diseases  of  women,  none  has  been,  or  is,  more  important 
than  that  of  Professor  Courty,  of  Montpellier.  It  is  the  carefully  elaborated  and 
repeatedly  revised  work  of  a  man  at  once  imbued  with  the  science  and  immersed  in 
the  practice  of  gynecology;  of  one  who  has  long  lived  in  a  centre  of  general  science 
and* learning,  amidst  an  abounding  population,  and  who  enjoys  the  great  advantage  ol 
combining  in  his  sphere  of  practical  activity  both  hospital  and  private  patients — two 
classes  which  differ  in  their  circumstances,  and  in  their  aspects  for  observation,  favor- 
able and  unfavorable  to  the  student. 

This  translation  of  a  work  on  women  has  been,  with  striking  appropriateness, 
executed  by  a  woman  doctor.  I  have  had  the  privilege  of  her  friendship  since  her 
childhood,  and  know  her  excellent  qualities.  She  has  already,  by  original  work,  shown 
her  competence,  in  an  important  respect,  for  this  now  completed  task  of  translation. 
But  she  is,  in  addition,  specially  qualified,  having  studied  in  the  University  of  Mont- 
pellier, under  Dr.  Courty,  among  others,  and  having,  subsequently  to  her  graduation, 
been  for  a  considerable  time  his  assistant  in  practice.  Moreover,  since  she  settled  in 
Edinburgh,  Dr.  M'Laren  has,  in  her  own  practice,  maintained  her  familiarity  with  the 
diseases  treated  of  in  this  book. 

Courty's  work  has,  since  its  first  publication,  been  recognized  everywhere.  In 
France  its  position  is  attested  by  the  sale  of  two  editions,  numbering,  I  am  told,  ten 
thousand  copies,  and  by  the  appearance  of  another,  the  third  edition.  It  is  from  this 
third  edition  that  this  translation  has  been  made.  As  it  now  appears,  it  is  a  treatise  on 
the  diseases  of  the  Uterus,  Fallopian  Tubes  and  Ovaries,  with  an  introductory  chapter  on 
the  anatomy,  physiology  and  teratology  of  the  organs  of  generation.  I  recommend  to 
the  careful  study  of  my  professional  brethren  a  book  which  has  already  been  crowned 
by  the  Institute  of  France.  J.  Matthews  Duncan. 

OUTLINE   OF   CONTKNTS. 

Introduction. — On  the  Anatomy,  Physiology,  and  Teratology  of  the  Organs  of  Generation.  Part  i. — Geheral 
Survey  of  Uterine  Diseases.  Diagnosis  of  Uterine  Diseases  in  General ;  Treatment  of  Uterine  Diseases  in 
General;  General  Characteristics  of  Uterine  Diseases.  Part,  ii — Uterine  Diseases  in  Detail.  Functional 
Disorders;  Changes  of  Position;  Morbid  States  without  Neoplasm;  Organic  Alterations;  Diseases  of  the 
Uterine  Appendages  ;  Pelvic  Hemorrhages  and  Peri-uterine  Haematocele ;  Cyst  of  the  Ovary  and  Genito-pelvic 
Tumor;  Sterility,  etc.,  etc      Index. 

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THE  CHANGE  OF  LIFE 

IN  HEALTH  AND  DISEASE. 

BY  EDWARD  JOHN  TILT,  M.D. 
FOTJETH  EEVISED  EDITION. 

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"We  jbelieve  Dr.  Tilt  brings  much  more  tlian  ordinary  merit  to  bear  on  his  subject, 
and  handles  it  accordingly.  No  recent  researches  in  physiology  or  pathology  which 
have  any  bearing  are  overlooked  by  him',  and,  as  a  result  of  his  method,  a  completeness 
attaches  to  each  of  the  subjects  treated  which  greatly  increases  the  value  of  the  work. 
It  will  be  seen  the  subjects  are  of  a  kind  most  cursorily,  if  at  all,  elsewhere  discussed, 
and  the  work,  therefore,  contains  information  nowhere  else  to  be  obtained.  Few  books 
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"  Dr.  Tilt  has  now  fairly  occupied  the  field  with  a  work  which,  if  it  does  not  include 
all  that  is  known  upon  the  diseases  of  the  climacteric  period,  is  at  all  events  a  repertory 
of  information  upon  a  subject  not  very  generally  understood.  The  work  is  divided  into 
twelve  chapters  ;  the  first  five  are,  an  introductory  one  on  the  physiology  of  the  change 
of  life,  one  on  its  pathology,  one  on  its  therapeutics,  and  one  on  its  hygienics.  Then 
follow  chapters  which  treat  consecutively  of  the  diseases  of  the  reproductive  organs  at 
this  period  of  life,  of  the  diseases  of  the  digestive  organs,  and  of  the  skin  ;  the  tenth 
treats  of  the  diseases  of  the  ganglionic  nervous  system,  and  the  eleventh  of  the  cerebro- 
spinal affections ;  and  the  concluding  chapter  is  miscellaneous.  Thus  the  subject  of 
climacteric  derangements  is  pretty  nearly  exhausted,  and  additional  value  is  given  to 
the  volume  by  numerous  interesting  tables,  which  exhibit  various  physiological  and 
pathological  facts  in  a  clear  and  definite  manner. 

"There  is  a  fund  of  practical  matter  in  Dr.  Tilt's  book,  and  no  small  share  of 
theory  also,  which  is  very  clearly  enunciated.  As  the  best  work  on  the  subject  of  which 
it  treats,  we  can  cordially  recommend  it  to  the  profession." — London  Lancet. 

"Additional  value  is  given  to  the  volume  by  numerous  interesting  tables,  which 
exhibit  various  physiological  and  pathological  facts  in  a  clear  and  definite  manner.  As 
a  work  containing  a  large  amount  of  valuable  practical  information  upon  a  subject 
not  very  generally  understood,  we  cordially  recommend  it  to  the  profession." — Chicago 
Medical  Examiner. 

"  Dr.  Tilt's  clear  and  concise  style  makes  the  book  at  once  a  pleasant  one  to  read 
and  an  easy  guide  to  follow,  and  we  are  quite  sure  it  is  the  most  valuable  one  we  have 
on  the  subject." — Boston  Medical  and  Surgical  Journal. 


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Obstetric  Operations,  Diseases  of  the  Puerperal  State,  Sec,  &c.  By 
Alfred  ISIeadows,  M.  D.,  Physician  to  the  Hospital  for  Women,  to 
the  General  Lying-in  Hospital,  &c.,  &c.  Revised  and  Enlarged  Edi- 
tion.    With  numerous  Illustrations.  Price  ;^2.oo 

In  this  new  edition, ..  .not  merely  is  the  practical  treatment  of  Labor,  and  also  of  the  Dis- 
eases  and  Accidents  of  Preguaucy,  well  and  clearly  taught,  but  the  anatomical  machinerj), 
of  parturition  is  more  effectively  explained  than  in  any  other  treatise  that  we  remember ; 
besides  this,  the  book  is  honorably  distinguished  among  manuals  of  Midwifery  by  the  ful* 
ness  with  which  it  goes  into  the  subject  of  the  strticture  and  develojjment  of  the  ovum.  Oa 
all  questions  of  treatment,  whether  by  medicines,  by  hygienic  regimen,  or  by  mechanical  oif 
operative  appliances,  this  treatise  is  as  satisfactoiy  as  a  work  of  manual  size  could  be ;  student* 
and  practitioners  can  hardly  do  better  than  adopt  it  as  their  vade-mecum. — The  Practitioner. 

Upwards  of  ninety  new  engravings  have  been  inserted  in  this  edition,  and,  with  a  view  to 
facilitate  reference,  the  author  has  furnished  it  with  a  very  full  and  complete  table  of  contents 
and  index.  "We  can  cordially  recommend  this  manual  as  accurate  and  practical,  and  as  con- 
taining in  a  small  compass  a  large  amount  of  the  kind  of  information  suitable  alike  to  the 
student  and  practitioner. — London  Lancet. 

It  is  concise,  well  arranged,  and  remarkably  complete,  as  a  guide  to  the  student  during  his 
lecture  term ;  and  as  a  ready  reference  to  the  Physician,  no  work  of  similar  character  equals 
it  iu  value. — Buffalo  Medical  Journal. 

The  systematic  arrangement  of  subjects,  and  the  concise,  practical  style  in  which  it  is 
written,  make  the  work  especially  valuable  as  a  student's  manual,  while  a  very  full  table 
of  contents  and  index  renders  it  easily  accessible  as  a  work  of  reference. — Chicago  Medical 
Examiner. 

There  can  be  no  doubt  that  this  manual  will  be  generally  accepted  as  a  brief,  convenient, 
and  compendious  guide  to  the  study  and  practice  of  the  Obstetric  Art. — Richmond  and 
Louisville  Medical  Journal. 

We  cannot  btit  feel  that  every  teacher  of  obstetrics  has  good  cause  to  con,gratulate  himself 
on  being  able  to  put  in  the  hands  of  the  student  a  book  which  contains  so  much  valuable 
and  reliable  information  in  so  condensed  a  form. — Philadelphia  Medical  Times. 

It  is  concisely  and  clearly  written,  and  the  information  is  on  the  whole  on  a  level  with  the 
most  recent  knowledge  of  the  day. — British  and  Foreign  Medical  Review. 

A  work  which  embodies  a  larger  amount  of  practical  information  than  any  other  book  on 
the  subject. — Pacific  3Ledical  and  Surgical  Journal. 

It  is  with  great  gratification  that  we  are  enabled  to  class  Dr.  Meadows'  Manual  as  a  rare 
exception,  and  to  pronotince  it  an  accurate,  practical,  and  creditable  work,  and  to  unhesi- 
tatingly recommend  it  to  both  student  and  practitioner. — American  Journal  of  Obstetrics. 

It  is  a  book  of  decided  merit :  every  pasre  teems  with  sound,  practical  common  sense,  advice 
and  suggestions. — Kansas  City  Medical  Journal. 


GRAILY  HEWITTS 

DISEASES  OF  WOMEN. 

FOURTH    AMERICAN,    FROM    THE    LAST    REVISED    AND    ENLARGED    LONDON    EDITION. 
WITH   NUMEROUS  BEAUTIFULLY  EXECUTED  ILLUSTRATIONS. 

This  Edition  of  Gi^aily  Hewitt' s  Celebrated  Woi^k  on  The  Dis- 
eases of.  Women,  as  now  issued  in  two  parts  in  P.  Blakiston,  Son  & 
Co.'s  Octavo  Series  of   Standard  Medical  Works,  the  two 

paints  containing  750  large  octavo  pages,  cleaidy  printed  fT-om  small 
pica  type,  leaded,  with  all  the  Illustrations  of  the  English  Edition, 
is  published  by  special  arrangement  with  the  author,  made  through 
his  publishers,  Messrs.  Longmans  &  Co.,  of  Londojt,  to  who7n  a 
large  amount  ivas  paid  for  an  advance  copy. 

THE  TWO  PARTS  IN  ONE  VOLUME. 
Handsomely  bound  in  Cloth,  Price,  -  -         $2.50 

Strongly  bound  in  Paper  Covers,  Price,  -  -  1.50 

The  Pathology,  Diagnosis,  and  Treatment  of  Diseases  of  Women,  including  the 
Diagnosis  of  Pregnancy.  Founded  on  a  Course  of  Lectures  Delivered  at  St. 
Mary's  Hospital  Medical  School.  By  Graily  Hewitt,  m.d.,  Lond.,  m.r.c.p.. 
Physician  to  the  British  Lying-in  Hospital ;  Professor  of  Midwifery  and  Diseases 
of  Women,  University  College,  and  Obstetric  Physician  to  the  Hospital,  etc. 
The  Fourth  American  from  the  Last  London  Edition.  Revised  and  Enlarged, 
with  many  New  Illustrations.     Octavo. 

The  author,  in  his  preface  to  this  edition,  says : —   ■  i 

"This  new  edition  of  my  treatise  on  The  Diseases  of  Women  is  substantially  a  new  work. 
It  has  been  made  more  systematic,  from  a  pathological  point  of  view;  many  new  illustrations  have 
been  added,  the  greater  part  of  them  being  carefully  prepared  representations  of  cases  coming 
under  my  own  observation." 

"  Readers  of  the  former  editions  will  not  require  to  be  I  "The  excellent  work  of  Dr.  Hewitt  presents — in  a 
told  that  the  additions   now  made   are   of    the  highest    ]    form  well  adapted  to  conduct  the  student  to  a  knowledge 


possible  excellence." — Thnes  and  Gazette. 
-  "  It  is  one  of  the  most  useful,  practical,  and  compre- 
hensive works  upon  the  subject  in  the  English  language, 
a  true  guide  to  the  student,  and  an  invaluable  means  of 
reference  for  the  teacher." — iV.   I'.  Medical  Record. 


of  the  Diseases  of  Women,  and  to  assist  the  young  prac- 
titioner in  his  study  of  these  diseases  at  the  bf-dside  cf 
the  patient — a  very  full  and  clear  exposition  of  the  views 
entertained  by  the  most  authoritative  teachers  as  to  their 
pathological  treatment  and  their  correct  Diagnosis." — 
Ainer.  Med.  Journal. 


ALSO,  NOW  READY, 


THE   FOURTH   EDITION,    REVISED   AND    ENLARGED,  WITH 
COLORED  PLATES,  AND  WOOD   ENGRAVINGS;  318  PAGES. 

Price  in  Paper  Covers,  75  Cents,  or  Bound  in  Cloth,  $L25. 

The  Nature,  Varieties,  and  Treatment  of  Sore  Throat,  including  the  Connection 
between  Affections  of  the  Throat  and  other  diseases.  By  Prosser  James,  m.d., 
Physician  to  the  Hospital  for  Diseases  of  the  Throat  and  Chest.  Fourth  Edition, 
Enlarged  and  Revised.  Illustrated  by  Colored  Plates  and  Wood  Engravings, 
One  volume,  i2mo,  318  pages. 

This  book  is  also  issued  in  this  country  by  special  arrangement  with  the  author.  It  is  printed  on 
good  paper,  with  a  clear  and  distinct  type,  with  illustrations  from  the  latest  London  edition,  and  is 
the  only  authorized  and  complete  edition. 

P.  BLAKISTON,  SON  h  CO.,  PuWishers,  1012  Walnut  Street,  Philadelpliia,  Pa. 


NOW  READY,  THE  SEVENTH  REVISED  EDITION. 

MEIGS  AND  PEPPER,  ON  CHILDREN. 

THE  MOST  THOROUGH,  COMPLETE  AND  PRACTICAL  WORK 
ON  THE  SUBJECT  NOW  BEFORE  THE  PROFESSION.     ■ 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  OF  CHILD- 
REN. By  J.  Forsyth  Meigs,  m.d.,  one  of  the  Physicians  to  the  Pennsylvania 
Hospital,  Consulting  Physician  to  the  Children's  Hospital,  etc.,  and  Willlam 
Pepper,  m.d.,  Professor  of  Clinical  Medicine,  University  of  Pennsylvania,  Provost 
and  ex- officio  President  of  the  Faculty,  Physician  to  the  Philadelphia  Hospital, 

Fellow  of  the  College  of  Physicians,  etc.,  etc.     The  Seventh  Revised  and  Improved 

Edition.     In  one  volume  of  over  iioo  royal  octavo  pages. 

Price,  handsomely  bound  in  Cloth,  $6.00;  Leather  $j.oo. 

The  rapid  sale  of  six  large  editions  of  Drs.  Meigs  and  Pepper's  work  on  Children, 
and  the  demand  for  the  new  edition  now  ready,  is  sufficient  evidence  of  its  great 
popularity.  The  large  practice,  of  many  years'  standing,  of  the  authors,  imparts  to  it  a 
value  unequaled,  probably,  by  any  other  on  the  subject  now  before  the  profession. 

The  entire  work  has  been  now  again  subjected  to  an  entire  and  thorough  revision, 
some  articles  have  been  rewritten,  many  additions  made,  and  great  care  observed  by 
the  authors,  that  it  should  be  most  effectually  brought  up  to  the  light,  pathological 
and  therapeutical,  of  the  present  day. 

The  publishers  have  very  many  favorable  notices  of  the  previous  editions,  re- 
ceived from  numerous  sources,  foreign  and  domestic.  They  append  a  few  from  lead- 
ing journals,  which  will  give  a  general  idea  of  the  value  placed  upon  it,  both  as  a 
Text-Book  for  the  Student  and  a  work  of  reference  for  the  Ge7ieral  Practitioner. 

"  It  is  the  most  complete  work  upon  the  subject  in  our  language ;  it  contains  at  once  the  results  of  personal  and 
the  experience  of  others ;  its  quotations  from  the  most  recent  authorities,  both  at  home  and  abroad,  are  ample,  and 
we  think  the  authors  deserve  congratulations  for  having  produced  a  book  unequaled  for  the  use  of  the  student, 
and  indispensable  as  a  work  of  reference  for  the  practitioner." — American  Medical  'jfozir7ziil . 


"  But  as  a  scientific  guide  in  the  diagnosis  and  treatment  of  the  diseases  of  children,  we  do  not  hesitate  to  say 
that  we  have  seldom  met  with  a  text-book  so  cor--Dlete,  so  just,  and  so  readable,  as  the  one  before  us,  which  in  its 
new  form  cannot  fail  to  make  friends  wherever  :t  saall  go,  and  wherever  great  erudition,  practical  tact,  and  fluent 
and  agreeable  diction  are  appreciated." — American  yournal  of  Obstetrics. 


"  It  is  only  three  years  since  we  had  the  pleasure  of  recommending  the  Fifth  Edition  of  this  excellent  work. 
With  the  recent  additions  it  may  safely  be  pronounced  one  of  the  best  and  most  comprehensive  works  on  diseases 
of  children  of  which  the  American  Practitioner  can  avail  himself,  for  study  or  reference.'' — iV.  K.  Jlfed.  yaurnai. 


"  It  is  not  necessary  to  say  much,  in  the  way  of  criticism,  of  a  work  so  well  known.  But  it  is  clinical.  Like  so 
many  other  good  American  medical  books,  it  mar\'elously  combines  a  rSszinze  of  all  the  best  European  literature 
and  practice,  with  evidence  throughout  of  good  personal  judgment,  knowledge,  and  experience.  The  book  also 
abounds  in  exposition  of  American  experience  and  observation  in  all  that  relates  to  the  diseases  of  children.  We 
are  glad  to  add  it  to  our  library.  There  are  few  diseases  of  children  which  it  does  not  treat  of  fully  and  wisely,  in 
the  light  of  the  latest  physiological,  pathological,  and  therapeutical  science." — London  Lancet. 

R  BLAKISTON,  SON  &  CO.,  Publishers, 

Successors  to  LINDSAY  &  BLAKISTON, 

1012  WALNUT  STREET,  PHILADELPHIA. 


